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MEDICAL COVERAGE
Our medical package provides a limited benefit accident plan as well as a sickness plan. The package also combines non- occupational coverage with the value of a discounted PPO network to stretch your benefit dollars.
Some highlights ....
| | - | The provider referral service gives you access to the names of in-network PPO providers.
| | - | A $15 co-pay on office visits for in-network doctor's fees (doesn't include tests, lab fees, x-rays, injections and other items covered under the outpatient benefits.)
| | - | Your enrolled dependents receive the same coverage.
| When you enroll in this plan, you also receive these additional benefits ....
| | - | An eyewear discount card that provides savings of up to 60% on eyewear purchases for your whole family at participating providers (eye exams not covered.)
| | - | A prescription drug discount card that saves your family up to 20% on prescriptions at over 95% of retail drug stores.
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| BENEFIT | IN ... 8 | OUT ... 8 | HOSPITAL IN-PATIENT
Base Max. Benefit 1
Subject to these limits:
- Hospital Room & Brd
$250 per day
- Surgeon's Fees
$1,500 per year
- Anesthesiologist Fees
$250 per year
- Hospital Room & Brd
$1,000 per year | $7,500 | $7,500 | | Base Benefit % Paid 5 | 50% | 50% | | Base Deductible 1,2,3 | $200 | $300 | | Suppl. Max. Benefit 4 | $45,000 | $45,000 | | Suppl. Benefit % Paid 5 | 80% | 60% | OUT-PATIENT 9
Maximum Benefit 1 | $1,000 | $1,000 | | Deductible 1,2,3 | $100 | $300 | | Base Benefit % Paid 5 | 70% | 50% | | Office Visit Dr's Fees | $15 co 6,7,8 | 50% 5,7 |
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| 1 | Per coverage year. | | 2 | The maximum per person deductible on combined eligible inpatient and outpatient charges from in-network
providers is $300 each coverage year ($600 for out-of-network providers.) | | 3 | You will have met your ?family deductible? when two covered family members have each paid their own deductibles in a coverage year. | | 4 | Maximum lifetime benefit. Each year the hospital in-patient base benefit must be exhausted before the supplemental benefit can begin. Other hospital services are not covered under this benefit. | | 5 | Where benefit is expressed as a percentage, the lower of the U&C fee levels or the discounted PPO charges will be the basis of payment. | | 6 | Not subject to a deductible. | | 7 | Subject to the Maximum Benefit for covered outpatient expenses. | | 8 | If you live in an area that is not served by the PPO network, and you use a non-participating provider that is also located outside a network area, your covered expenses would be reimbursed according to the in-network provisions of the plan. An exception to this is the Office Visit Doctors? Fees, for which there is no co-pay and the provisions of the in-network outpatient benefit would apply (70% of eligible charges after a $100 deductible.) | | 9 | Outpatient prescription drugs are covered under the in-network provisions of this benefit. |
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DENTAL COVERAGE
Highlights of our dental coverage plan ....
| | - | The freedom to use any dentist you choose.
| | - | A $500 coverage year maximum after a $50 deductible.
| | - | Your enrolled dependents receive the same coverage.
| | - | The plan covers most common dental services.
| NOTE:
Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. The plan will pay only for the procedures specified on the Schedule of Benefits in the SPD. Usual, reasonable, and customary limitations are based on the 90th percentile of the Medicode MDR tables. |
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| Chrgs Covered | % Paid | Waiting Period | | Check-ups | 80% | None | | Fillings | 60% | 3 Months | | Oral Surgery | 60% | 3 Months | | Crown and Bridge Repair | 60% | 3 Months | | Denture Repair | 60% | 3 Months | | Perio and Endodontic Services | 50% | 12 Months | | Crown/ Bridge | 50% | 12 Months | | Dentures | 50% | 12 Months |
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VISION COVERAGE
Highlights of our vision coverage plan ....
| | - | Reimbursements of $25 for an eye examination once every 12 months.
| | - | Simply file a claim and receive a reimbursement.
| | - | An Eye Care Plan of America (ECPA) Discount Card.
| | - | Save up to 60% on eyewear at participating ECPA centers (10% on contact lenses and other optical items.)
| | For more information on participating ECPA centers or a provider directory, log onto their website at www.ecpa.com. |
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TERM LIFE WITH ACCIDENTAL DEATH BENEFIT (ADB)
Highlights of our ADB coverage plan ....
| | - | The freedom to use any dentist you choose.
| | - | The freedom to use any dentist you choose.
| | - | The freedom to use any dentist you choose.
| | - | If you sign up for term life for yourself, you can enroll your eligible dependents for: 1) $2,500 in term life only for dependents over 6 months, or 2) $500 for children 6 months of age or younger.
| | - | Your benefits are reduced by 50% at age 70. Dependent term life benefits end when they reach age 70. |
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