Here is a comparison of your medical plan options available for 2011.
|
Feature/Service
|
Traditional PPO
Plan
|
Health Choice Savings
Plan
|
|
In-Network
|
Out-of-Network
|
In-Network
|
Out-of-Network
|
| Outpatient
Services |
| Primary Care Office Visit |
$25
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Specialty Visit |
$35
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Annual Physical (Routine Physical Exam
- Adult, 16 years +) |
100%
|
60% covered after deductible
|
100%
|
100% covered after deductible
|
| Routine Mammogram (1/year) |
100%
|
60% covered after deductible
|
100%
|
100% covered after deductible
|
| Routine OB/GYN Exam (1/year) |
100%
|
60% covered after deductible
|
100%
|
100% covered after deductible
|
| Well Child Care (Routine
Physical Exam - Child) |
100%
Child: First 12 months of life: 6 exams; 2
to 3 years: 2 exams; 4-15 years: 1 exam/calendar year
|
60% covered after deductible
|
100%
Child: First 12 months of life:
6 exams; 2 to 3 years: 2 exams; 4-15 years: 1 exam/calendar
year
|
100% covered after deductible
|
| Immunizations |
100%
|
60% covered after deductible
|
100%
|
100% covered after deductible
|
| Short Term Rehab Visits |
$35 co-pay (60 visit limit)
|
60% covered after deductible (60 visit limit)
|
100% covered after deductible (60 visit limit)
|
100% covered after deductible (60 visit limit)
|
| Diagnostic Radiology and
Laboratory Services |
80% covered after deductible
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Chiropractic Care |
$35 co-pay (20 visit limit)
|
60% covered after deductible (20 visit limit)
|
100% covered after deductible (20 visit limit)
|
100% covered after deductible (20 visit limit)
|
| Hospital
|
| Inpatient Hospital Admissions
- Facility Charge |
80% covered after deductible
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Associated Professional
Services |
80% after the deductible
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Outpatient Surgery |
80% covered after deductible, $35 in office
|
60% covered after deductible
|
100% covered after deductible
|
100% covered after deductible
|
| Emergency Care
|
| Life Threatening |
100% after $100 co-pay (waived if admitted immediately)
|
100% after $100 co-pay (waived if admitted immediately)
|
100% covered, waive deductible
|
100% covered, waive deductible
|
| Prescription
Drugs*
|
| Retail-30 day supply |
Generic: $10 co-pay
Formulary: 20% co-insurance ($30 min to $50 max)
Non-Formulary: 30% co-insurance ($50 min to $75 max)
|
In-Network Benefit Only
|
100% covered after deductible
|
In-Network Benefit Only
|
| Mail Order-90 day supply |
Generic: $20 co-pay
Formulary: 20% co-insurance ($50 min to $90 max)
Non-Formulary: 30% co-insurance ($90 min to $130 max)
|
In-Network Benefit Only
|
100% covered after deductible
|
In-Network Benefit Only
|
| Additional Services |
Oral & Injectable Contraceptives-covered;
Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered;
Impotency Drugs-covered, limited to 8 pills per month at retail
and not covered under mail order; Infertility Drugs-not covered
|
In-Network Benefit Only
|
Oral & Injectable Contraceptives-covered;
Smoking Cessation Drugs-covered; Weight Loss Drugs-not covered;
Impotency Drugs-covered, limited to 8 pills per month at retail
and not covered under mail order; Infertility Drugs-not covered
|
In-Network Benefit Only
|
| Specialty Mail Order - 30 day Supply |
Generic: $7 co-pay
Formulary: 20% co-insurance ($17 min to $30 max)
Non-Formulary: 30% co-insurance ($30 min to $43 max)
|
In-Network Benefit Only
|
100% covered after deductible
|
In-Network Benefit Only
|
| Diabetic Supplies, 90-day supply for
Retail or Mail Order |
Includes: Needles/Syringes and Insulin; Test
Strips; Lancets-20% copay ($25 min to $45 max)
|
In-Network Benefit Only
|
100% covered after deductible
|
In-Network Benefit Only
|
| Mental Health
and Chemical Dependency Rehabilitation |
| Outpatient Mental Health Visits |
$35 copay
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Inpatient Mental Health - Facility
Charge |
80% after the deductible
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Associated Professional
Services |
80% after the deductible
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Outpatient Chemical
Dependency Visits |
80% after the deductible
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Inpatient Chemical Dependency-
Facility Charge |
80% after the deductible
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Associated Professional Services
|
80% after the deductible
|
70% after deductible
|
100% covered after deductible
|
100% after deductible
|
| Deductibles
|
| Individual |
$500
|
$1,000
|
$2,000
|
$4,000
|
| Individual + 1 |
$1,000
|
$2,000
|
$4,000
|
$8,000
|
| Family |
$1,000
|
$2,000
|
$4,000
|
$8,000
|
| Co-Insurance
Maximum
|
| Individual |
$2,000
|
$3,000
|
$2,000
|
$4,000
|
| Individual + 1 |
$4,000
|
$6,000
|
$4,000
|
$8,000
|
| Family |
$4,000
|
$6,000
|
$4,000
|
$8,000
|
| Other Information |
| Lifetime Maximum |
No Lifetime Maximum
|
| Member Services Phone Number |
1-866-262-1180
|
| Web site address |
|