PPA=Preferred Provider Allowance, the amount accepted as payment in full by most Preferred professionals and pharmacies.
Certain deductibles and coinsurance amounts do not apply if Medicare is the primary coverage for medical services.
On limited occasions, such as for certain drugs requiring prior approval, you will need to file a claim for services received from Preferred providers.
SERVICES | |
Preventive Services |
STANDARD OPTION |
| Preventive screenings: Pap Smear, mammogram, stool tests for blood, prostate specific antigen tests, routine cancer screenings, cholesterol tests, sigmoidoscopies and related office visit charge (See the 2001 Service Benefit Plan brochure for timeframes.) |
~You pay only $15 for each related office visit
|
| Routine physical exams, including a history and risk assessment, chest x-ray, EKG, urinalysis, CBC and metabolic panel test once every 3 years for members aged 22-64; annually at age 65 and older | ~You pay only $15 for the office visit ~Related preventive screening tests are covered in full, with no deductible |
| Influenza & Pneumonia Immunizations - once every calendar year. | ~$15 office visit co-payment ~Immunization paid in full |
| Well Child Care up to age 22 | Paid in full |
| Dental Care for services listed in the Service Benefit Plan brochure fee schedule | ~Your out-of-pocket costs are limited to a Maximum Allowable Charge (MAC) ~Benefits paid according to the fee schedule in the Service Benefit Plan brochure |
Physician Care | STANDARD OPTION PPO BENEFIT |
| Inpatient services, including surgical and medical care | ~90% PPA, your cost is 10% PPA ~Subject to $250 calendar year deductible |
| Outpatient surgery and diagnostic tests such as x-rays, laboratory tests and machine diagnostic tests | ~90% PPA, your cost is 10% PPA ~Subject to $250 calendar year deductible |
| Home and office visits, second surgical opinions and outpatient consultations | ~You pay only $15 for the visit charge, with no deductible |
| Outpatient physical, occupational and speech therapy
| ~90% PPA, your cost is 10% PPA ~Subject to $250 calendar year deductible ~Physical therapy; 50-visit maximum per year ~Occupational and speech therapy; combine maximum of 25 visits per year |
Maternity Care | STANDARD OPTION PPO BENEFIT |
| Inpatient Hospital care - Pre-certification is not required | ~Paid in full |
| Physician care including delivery and pre- and post-natal care | ~100% with no deductible |
Prescription Drugs | STANDARD OPTION PPO BENEFIT |
| Mail Service Pharmacy | ~Paid in full after $12 co-payment for generic drugs ~Paid in full after $20 co-payment for brand name drugs ~90-day limit per prescription or refill |
| Retail Pharmacy | ~You pay only 25% PPA at the time of purchase ~No prescription drug deductible ~90-day limit per prescription or refill |
Hospital/Facility Care | STANDARD OPTION PPO BENEFIT |
| Hospital inpatient room and board and other inpatient hospital services. Pre-certification is required | ~Unlimited days ~Paid in full with $100 per admission co-payment |
| Hospital/Facility care; Outpatient surgery | ~90% PPA, your cost is 10%PPA |
| Hospital/Facility care; (other than services related to surgery or accidental injury) outpatient services including medical emergency care,diagnostic tests, renal dialysis, radiation therapy, chemotherapy, and physical, occupational and speech therapy. | ~90% PPA, your cost is 10%PPA ~Subject to $250 calendar year deductible ~Physical therapy; 50-visit maximum per year ~Occupational and speech therapy; combined maximum of 25 visits per year |
| Accidental Injury - covered charges in connection with and within 72 hours after an accidental injury at a facility or in a physician's office. Includes outpatient medical care and diagnostic tests. | ~We pay covered charges in full |
Other Services | STANDARD OPTION PPO BENEFIT |
| Home Hospice Care Prior Approval required | Paid in full |
| Home Nursing Care | ~Two hours per day maximum ~75% Allowable charge ~25 visits per year ~Subject to $250 calendar year deductible |
| Home Health Care | Not covered |
| Smoking Cessation | ~Paid in full, up to $100 ~One treatment program per person per lifetime ~Subject to $250 calendar year deductible |
| Catastrophic Protection
| ~100% payment level begins after you pay $3,000 out-of-pocket in coinsurance, co-payment and deductible expenses for preferred providers |
Mental Conditions and Substance Abuse | STANDARD OPTION PPO BENEFIT |
| Inpatient Hospital - mental conditions Pre-certification is required | ~In full after $100 per admission co-payment |
| Inpatient Hospital - substance abuse Pre-certification is required | ~In full after $100 per admission co-payment |
| Outpatient Facility Care - Mental Conditions and substance abuse |
~Subject to $250 calendar year deductible. |
| Outpatient Professional Care | ~$15 co-payment per visit ~Treatment plan needed prior to 9th visit |
| Inpatient Professional Care | ~Subject to $250 calendar year deductible ~You pay 10% PPA |