BENEFITS |
PPO |
NON-PPO |
Primary Doctor Office Visit |
$14 per visit |
40% after deductible ($20
per visit limit Fund will pay) |
Specialist Doctor Office Visit |
$20 per visit |
40% after deductible ($20
per visit limit Fund will pay) |
Injections/Immunizations
(routine preventative not covered at Non-PPO) |
$6 per procedure |
40% after deductible |
Allergy Testing
(UR required for testing)
|
$7 per test type |
40% after deductible |
I.V. Treatment |
$7 per visit |
40% after deductible |
Pulmonary
Treatment |
$5 per procedure |
40% after deductible |
X-ray |
$12 per procedure |
40% coinsurance |
|
Lab
(only if tests are processed at contracted lab
facilities) |
$5 per visit |
40% coinsurance |
Dialysis Management |
no copay |
40% coinsurance |
MRI/CT Scans
(PPO only)
|
$55 per
visit |
You pay all
(PPO Only) |
PET Scans
(PPO only) |
$155 per
procedure |
You pay all
(PPO Only) |
Chemotherapy |
$7 per visit |
40% after deductible |
Radiation Therapy |
$7 per visit |
40% after deductible |
Chiropractic (PPO only) |
$14 per service
You pay for orthotics. |
You pay all
(PPO only) |
Hospital (in-patient) |
$250 deductible |
40% after $500 copay per admission |
Ambulance |
Ground
no deductible
20% coinsurance
$1,500 maximum benefit per calendar year per
person |
Air
$500/person $1,000/family deductible
no coinsurance |
ER (True Emergency) |
$150 per visit |
40% after deductible ($200 limit Fund will pay) |
ER (Not True Emergency) |
$150 per visit + 40% of cost up ($500 limit Fund will pay) |
40% after deductible ($200 limit Fund will pay) + $50 copay per incident |
Dental |
Plan A
Copays varies by services –
see complete list of copays - $850 Orthodontics |
Plan B
$1500 maximum benefit, payments according to a set fee schedules –
see complete list of what the Plan pays
|
Vision
|
$150 maximum benefit every 24 months per eligible person
Exams = $20 copay per visit, covered under your medical benefit |
Hearing Aids |
$300 maximum benefit during any 60 month period |
