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Medical / Vision

 

Medical

Prescription Drugs

Preventive Care

Vision

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Medical

Calendar Year Deductible            

$150 per Person / $300 per Family 

 

Most Services             

In-Network.....80% after Deductible 

Out-of-Network.....60% after Deductible

 

Calendar Year Coinsurance Maximum*

In-Network.....$1,500 Participant / $3,000 Family       

Out-of-Network.....$2,000 Participant / $4,000 Family

 

Lifetime Maximums           $4,000,000 per Participant

(All Benefits, All Plans)

 

*The following Expenses DO NOT APPLY to the Calendar Year Coinsurance

 Maximum:  Prescription Drug Expense Benefits, Co-Payments, Treatment for 

Substance Abuse, Non-precertification penalties, Preventive Care Benefits, 

and Accident Expense Benefits.

 

 

Type Of Service

In-Network Benefit 

(PPO Providers)

 Out-of-Network Providers
Hospital Confinements

 

 80% After Deductible  60% After Deductible
Physician Visits

 

 100% After $20 co-pay 70% After Deductible

Lab and/or X-Ray

(Independent Facility) 

 

 100% After $20 co-pay 60% After Deductible
Surgery in the Physician's Office

 

 100% After $20 co-pay 60% After Deductible
Surgery Other Than the Physician's Office 

 

 80% After Deductible  60% After Deductible
Accident Expense Benefit (Per Accident)

100% of the first $1,000 

then 80% After Deductible

100% of the first $1,000 

then 60% After Deductible

 

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Prescription Drugs

Prescription Drugs** 

 Advance Paradigm Contracted Pharmacies

 

Prescription Drug Card

 100% After $15 Generic co-pay / $25 Name Brand co-pay (30 Day Supply)

 

Mail Order Drug Program

100% After $20 Generic co-pay / $40 Name Brand co-pay

(90 Day Supply or $500 maximum per prescription)

 

 

**If a non-participating pharmacy is used, covered charges are limited to the amount that would have been allowed had a participating pharmacy been used.

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Preventive Care

 

 

Preventive Care

Calendar Year Maximum

 

 

Up through age 6                     No Maximum

Age 7 through 39                     $200

Age 40 through 49                   $400

Age 50 & Over                        $600

 

You do not need to pay $20 office co-pay for your Preventive Care benefit

 

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Vision


Examination

Lenses (other than Contact Lenses)****

Frames****

Contact Lenses

Surgical Correction

 

  

Payable at 100%, not subject to calendar year deductible, 

but is subject to $100 Calendar Year Maximum per Participant.

****Benefits for lenses, frames, and contact lenses are only available for the 

correction of visual acuity of the Participant and prescribed by a physician.

Benefits will not be allowed for non-prescription contact lenses, lenses, or frames.

 

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Employee Benefit Service Center