Do not rely on this chart alone.
All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, click on the link that is provided and it will take you to the section where a full description of benefits is available.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from 2007 Rates on your enrollment form.
Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see Section 3. There is no deductible for Basic Option.
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| BENEFITS |
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YOU PAY |
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| Medical Services Provided By Physicians: |
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Diagnostic and treatment services provided in the office
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PPO: $20 per office visit for primary care physicians and other health care professionals; $30 per office visit for specialists
Non-PPO: You pay all charges
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| Services Provided By A Hospital: |
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Inpatient |
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PPO: $100 per day up to $500 per admission
Non-PPO: You pay all charges
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| Outpatient |
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PPO: $40 per day per facility
Non-PPO: You pay all charges
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| Emergency Benefits: |
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Accidental injury |
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PPO: $50 copayment for emergency room care; $30 copayment for urgent care
Non-PPO: $50 copayment for emergency room care
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| Medical emergency |
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Same as for accidental injury
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| Mental Health And Substance Abuse Treatment: |
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In-Network (PPO) |
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Regular cost sharing, such as $20 office visit copayment (prior approval required); $100 per day up to $500 per inpatient admission
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| Out-of-Network (Non-PPO) |
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You pay all charges
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| Prescription Drugs: |
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Retail Pharmacy Program |
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PPO: $10 generic/$30 formulary brand name per prescription/50% coinsurance ($35 minimum) for non-formulary brand name drugs. 34-day maximum supply on initial prescription; up to 90 days for refills with 3 copayments
Non-PPO: You pay all charges
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| Dental Care: |
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PPO: $20 copayment per evaluation (exam, cleaning, and x-rays); most services limited to 2 per year; sealants for children up to age 16; $20 copayment for dental services required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
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| Special Features: |
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Flexible benefits option; online customer and claims service; 24-hour nurse line; services for deaf and hearing impaired; web accessibility for the visually impaired; travel benefit/services overseas; health support programs; and Healthy Families program
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| Protection Against Catastrophic Costs: |
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Your catastrophic protection out-of-pocket maximum |
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Nothing after $5,000 (PPO) per contract per year; some costs do not count toward this protection
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