| High Option Benefits |
You Pay |
Medical services provided by physicians:
• Diagnostic and treatment services provided in the office
|
PPO: $20 copayment per office visit
Non-PPO: 30%* of the Plan allowance
|
Services provided by a hospital:
• Inpatient
|
PPO: $200 copayment per confinement, nothing for room & board and 10% for other hospital services
Non-PPO: $300 copayment per confinement and 30% of the Plan allowance
|
• Outpatient
|
PPO: $100 per facility charge and 10% of the Plan allowance
Non-PPO: $150 per facility charge and 30%* of the Plan allowance
|
Emergency benefits:
• Accidental injury
|
Nothing within 72 hours
|
• Medical emergency
|
Regular benefits apply
|
Mental health and substance abuse treatment
|
In-Network: Regular cost sharing
Out-of-Network: Benefits are limited
|
Prescription drugs
• Retail Pharmacy
|
$10 generic, $30 preferred name brand or $45 non-preferred name brand copayment
Medicare Retail: $10 generic, $25 preferred name brand or $40 non-preferred name brand copayment
|
• Mail Order
|
$10 generic, $50 preferred name brand or $65 non-preferred name brand copayment
Medicare Mail Order: $10 generic, $30 preferred name brand or $50 non-preferred name brand copayment
|
Dental Care
• Diagnostic and treatment services provided in the office
|
PPO: 10%* of the Plan allowance for certain covered services
Non-PPO: 30%* of the Plan allowance for certain covered services
|
Special features:
Flexible benefits option; Travel benefit/services overseas; Services for deaf and hearing impaired; Online Resources; Healthy Rewards Program
|
Protection against catastrophic costs
(out-of-pocket maximum)
|
PPO: Nothing after $3,500 per calendar year
Non-PPO: Nothing after $5,000 per calendar year
Some costs do not count toward this protection
|
