|
Option III
Select
PPO
2 Medical
Plan -
Premera Blue Cross WEA
October 1, 2005
- September 30, 2006 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
|
In-Network |
Out-Of-Network |
|
PPO
Network |
Premera Blue Cross Preferred Providers |
Non-Preferred
Providers |
|
Deductible |
$100 Individual/$300
Family |
|
Coinsurance* |
80% |
60% |
|
Out-of-Pocket Max** |
$1,375/Individual |
$3,667/Individual |
|
Maximum
Benefit |
$5,000,000 revolving
every 5 consecutive years |
|
Office
Visits |
$25 copay, then 100% |
$30 copay, then 100% |
|
Preventive Care - $200/yr; $500 well-baby care/yr
(up to age 3) |
100% |
80% |
|
Diagnostic Lab
& X-ray |
80% after deductible |
60% after deductible |
|
Ambulance |
80% after deductible |
60% after deductible |
|
Hospital
Inpatient*** |
$150 copay per day; $450 max/yr, then 80%
after deductible
|
$150 copay per day; $450 max/yr, then 60%
after deductible
|
|
Emergency
Room |
$75 copay; waived if admitted |
|
Surgery: |
|
|
Inpatient*** |
$150 copay per day; $450
max/yr,
then 80% after deductible
|
$150 copay per day; $450 max/yr, then 60%
after deductible
|
|
Outpatient |
$100 copay, then 80%
after deductible |
$100 copay, then 60%
after deductible |
|
Chiropractic |
$25 copay, then 100% |
$30 copay, then 100% |
|
Psychiatric: |
|
|
Inpatient*** |
$150 copay per day; $450
max/yr, then 80% after deductible
|
|
Outpatient -
50 one-hour
visits/yr
|
70% after deductible |
50% after deductible |
|
Chemical Dependency: |
$12.500 maximum
every 24 months |
|
Inpatient*** |
$150 copay per day; $450
max/yr, then 80% after deductible
|
$150 copay per day; $450 max/yr, then 60%
after deductible
|
|
Outpatient
|
$25 copay, then 100% |
$30 copay, then 100% |
|
Retail Prescriptions
(Participating
Pharmacies)
|
Generic:
$10 copay
Preferred Brand: $20 copay
Non-Preferred Brand:
$35 copay
|
75%
of allowable charges after applicable copays |
|
RX
Dosages - Retail |
34-day supply Acute; 60-day supply Maintenance |
|
Mail Order Prescriptions
|
Generic:
$10 copay
Preferred Brand: $20 copay
Non-Preferred Brand:
$35 copay
|
75%
of allowable charges after applicable copays |
|
RX Dosages -
Mail Order |
100-day supply |
|
Vision
Care |
Not covered |
|
Life
Insurance |
$20,000 decreasing term life and AD&D for employee |
