BENEFITS

PPO

Primary Doctor Office Visit

$14 per visit

Specialist Doctor Office Visit

$20 per visit

Injections/Immunizations

$6 per procedure

Allergy Testing
(UR required for testing)

$7per test type

I.V. Treatment

$7 per visit

Pulmonary Treatment

$5 per procedure

X-ray

$12 per procedure

Lab

(Only if tests provided by contracted lab facilities)

$5 per visit

Dialysis Management

no copay

MRI/CT Scans (PPO Only)

$55 per visit

PET Scans (PPO Only)

$155 per procedure

Chemotherapy

$7 per visit

Radiation Therapy

$7 per visit

Chiropractic (PPO only)

$14 per service

Patient spay for orthotics.

Hospital (in-patient)

$250 deductible

Ambulance

Ground

no deductible

20% copay

Air

$500/person $1,000/family deductible

no copay

ER (True Emergency)

$150 per visit

ER (Not True Emergency)

$150 per visit + 40% of cost up ($500 limit Fund will pay)

Dental

Plan A

Copays varies by services – see complete list of copays - $850 Orthodontics

Vision

• Lenses
• Frames
• Contacts

$150 maximum benefit every 24 months per eligible person

Exams= $20 copay per visit, covered under medical benefit

Hearing Aids

$300 maximum benefit during any 60 month period

Tier 1

$5

all covered generic drugs

Tier 2

$15

covered brand drugs listed on the preferred drug list

Tier 3

$30

covered brand drugs that are not listed on the preferred drug list

$0

There is NO copay for medications that are available at the Culinary Free Pharmacy. Only medications that are listed on the “Free Drug List” are available at this pharmacy.