In-Network

Out-of-Network*

Annual Deductible Amount for injury, illness, or maternity

$300 / individual
$600 / family

$500 / individual
$1,000 / family

Out-of-Pocket Annual Limit (excludes deductible)

$1,500 / individual
$3,000 / family

$4,500 / individual
$9,000 / family

Pre-Existing Conditions

n/a

n/a

Maximum Lifetime Benefit (in-network and out-of-network combined)

$2,000,000

$2,000,000

Outpatient Short-Term Rehabilitation – 180 visits per year for all conditions, in-network and out-of-network combined.  Includes speech, occupational, physical and cardiac therapy

Covered 100%

Covered 60% of R&C*
after deductible

Outpatient laboratory and X-ray:

• All charges billed by an independent facility.

Covered 100%

Covered 60% of R&C* after deductible

Home Health Care
(skilled visits only)
Maximum number of hours per day is limited to 16 hours. Multiple visits can occur in one day; with a visit defined as a period of 2 hours or less.

Covered 100%; unlimited days

Covered 60% of R&C*
after deductible for up to 60 days per calendar year, reduced by any in-network days

Durable Medical Equipment

Covered 100%

Covered 60% of R&C*
after deductible

External Prosthetic Devices –
Requires approval by
Health Plan

Covered 90% after deductible and $100 copayment per appliance

Covered 60% of R&C* after deductible

Hospital Care

In-Network

Out-of-Network*

Inpatient Services: semi-private room, operating room, X-ray, and laboratory services. 
Includes stand-alone facilities such as Birthing Center.

Covered 90% after deductible and $250 copayment per admission

Covered 60% of
R&C* after deductible and $500 copayment per admission

Outpatient Services:

• Outpatient surgery

Covered 90% after deductible and $150 copayment per visit

Covered 60% of
R&C* after deductible and $300 copayment per visit

Transplant Coverage: 
Inpatient Facility

Covered 90% after deductible and $250 copayment at approved facilities

Covered 60% of R&C after deductible and $500 copayment per admission

Travel Benefit

$10,000 per transplant per lifetime available when using an approved facility

Not covered

Emergency Room Services (not covered if not a true Emergency)

Covered 100% after $100
copayment per visit if
true emergency (waived if admitted)

Covered 100% after $100 copayment per visit if true emergency (waived if admitted)

Ambulance Services (not covered if not a true Emergency)

Covered 100%

Covered 100%

Urgent Care Facility (not covered if not a true Emergency)

Covered 100% after $50 copayment

Covered 100% after $50 copayment

Inpatient Mental Health –
20 days per calendar year in-
network and out-of-network
combined

Covered 90% after deductible and $250 copayment per admission

Covered 60% of R&C* after deductible and $500 copayment per admission

Inpatient Alcohol and Drug
Abuse – two admissions per lifetime and 100 days per lifetime, in-network and out-of-network combined

Covered 90% after deductible and $250 copayment per admission

Covered 60% of R&C after deductible and $500 copayment per admission

Maternity – Inpatient

Covered 90% after deductible and $250 copayment per admission

Covered 60% of R&C after deductible and $500 copayment per admission

Inpatient Services at other healthcare facilities:

• Includes Skilled Nursing Facility, Rehabilitation Hospital and Subacute facility
• 60 days per calendar year for in-network and out-of-network combined

Covered 90% after deductible

Covered 60% of R&C

Hospice Care

• Inpatient

Covered 90% after deductible and $250 copayment per admission

Covered 60% of R&C after deductible and $500 copayment per admission

• Outpatient

Covered 100%, no copayment

Covered 60% of R&C
after deductible

Physician Care

In-Network

Out-of-Network*

Primary Care Office Visit

Covered 100% after $15 copayment

Covered 60% of R&C
after deductible

Specialist Office Visit

Covered 100% after $30 copayment

Covered 60% of R&C
after deductible

Vision Exam Services
Provided by VSP

No charge for yearly exam; no charge for standard frames every 24 months; no charge for standard lenses every 12 months; or reimbursement up to $75 for one pair of contact lenses (replaces all other benefits and includes exam)

Plan covers up to $25 toward yearly exam; up to $40 toward pair of frames every 24 months; lenses according to fee schedule or one pair of contact lenses every 12 months up to $75 (replaces all other benefits and includes exam)

Physician and Surgeon
Services in Hospital

Covered 90% after plan deductible

Covered 60% of R&C
after deductible

Maternity Office Visits

Covered 100% after one-time
office visit copayment

Covered 60% of R&C
after deductible

Maternity Delivery
(Physician charges)

Covered 90% after plan deductible

Covered 60% of R&C
after deductible

Preventive Health Services:

• Well-Baby Care

Covered 100% after $15 copayment (includes immunizations)

Not covered

• Routine Physical Exam

Covered 100% after $15 primary care office copayment

Not covered

• Routine Gynecological Exams

Covered 100% after $15 physician’s office copayment if physician used is contracted as primary care physician

Not covered

• Routine Mammogram

Covered at 100% (no referral needed)

Covered 60% of R&C* after deductible

• Hearing Aid Benefits

Covered at 100%; $750 maximum every 36 months

Hearing aid not covered

• Hearing Exam

Covered at 100% after $30 copayment per visit

Exam covered 60% after deductible

Chiropractic Care

Covered 100% after $30 copayment; 25 visit limit per year

Not covered

Substance Abuse – Outpatient

$30 copayment per visit for individual therapy; unlimited visits
$15 copayment per visit for group therapy; unlimited visits

Covered 60% R&C* after deductible; up to 35 visits per year, reduced by any in-network visits

Mental Health – Outpatient

$30 copayment per visit for individual therapy; unlimited visits
$15 copayment per visit for group therapy; unlimited visits

Covered 60% of R&C* after deductible; up to 35 visits per year, reduced by any in-network visits

Physician Services in
Emergency Room

Covered 100%

Covered 100%

Infertility Treatment:

Limited coverage; $20,000 lifetime maximum

Limited coverage; $20,000 lifetime maximum

Prescription Drugs, administered by Medco

Retail Prescription Drugs – up to a 30-day supply

$150 deductible for salaried employees and all retirees

$100 deductible for hourly employees (until January 1, 2006) then $150

Generic: 20% (minimum $10 copayment) after deductible

Brand: 30% (minimum $10 copayment) after deductible

If actual cost is under $10, then you pay actual cost

50% of cost after $150 deductible

Mail Order – Home Delivery

Salaried employees, retirees, and hourly employees after January 1, 2006:
Generic: $15 copayment up to a 90-day supply
Brand: $35 copayment up to a 90-day supply

Hourly employees (until January 1, 2006):
Generic: $5 copayment for up to a 90-day supply
Brand: $15 copayment for up to a 90-day supply

Not covered