MEDICAL PLANS FOR CALENDAR YEAR 2016
**PLAN**
BENEFIT PERIOD
Primary Care Physician (PCP) Required
Dependent age limit
Annual Deductible
Annual out-of-pocket max (excl deductible)
Coinsurance (employee pays)
IN-PATIENT CARE
Semi-private room and board
Surgery
Anesthesia
Consultations
Maternity care
Lab and X-ray services
Therapy services
Drugs and Medications
OUT-PATIENT CARE
Outpatient surgery
Second Surgical Opinion
Diagnostic services, lab and x-ray
MRI (require prior authorization)
Cardiac Rehabilitation
Physical, occupational and speech therapy
4
Office visits - PCP
Office visits - Specialist4
Urgent Care4
4
Routine Physical exam
Routine Testing (5 standard) 1
Well child care (birth to age18) 4
Immunizations
Routine Mammogram2
2
Routine Pap test
Routine PSA2
Routine Hearing Exam
Prenatal and postnatal maternity care
Sterilization
Allergy test and treatment
Durable medical equipment
Emergency room services (emergency)
3
- non-emergency use of emergency room
Ambulance
Biologically Based Mental Illness Services
Substance/Chemical Abuse
Inpatient
Outpatient benefit
Skilled nursing facilities
Home healthcare
Private Duty Nursing
Hospice
Organ transplants
Prescription Drug (CVS Caremark)
PPO Option 90/70 (Anthem & Med Mutual)
Calendar Year (January 1 to December 31)
No
age 26
BENEFIT
Network
Non-Network
$250/$500
$750/$1,500
$1,500/$3,000
10%
30%
PPO Option 80/60 (Anthem & Med Mutual)
Calendar Year (January 1 to December 31)
No
age 26
BENEFIT
Network
Non-Network
$350/$700
$900/$1,800
$2,000/$4,000
20%
40%
PPO Option 70/50 (Offered by Med Mutual ONLY)
Calendar Year (January 1 to December 31)
No
age 26
BENEFIT
Network
Non-Network
$500/$1,000
$1,000/$2,000
$2,500/$5,000
30%
50%
90%
90%
90%
90%
90%
90%
90%
90%
$100 copay, then 70%
70%
70%
70%
$100 copay, then 70%
70%
70%
70%
80%
80%
80%
80%
80%
80%
80%
80%
$100 copay, then 60%
60%
60%
60%
$100 copay, then 60%
60%
60%
60%
70%
70%
70%
70%
70%
70%
70%
70%
$100 copay, then 50%
50%
50%
50%
$100 copay, then 50%
50%
50%
50%
90%
100%
90%
90%
90%
90%
$15 copay then 100%
$30 copay then 100%
$15 copay then 100%
$15 copay then 100%
100%
$15 copay then 100%
100%
100%
$15 copay then 100%
100%
$15 copay then 100%
90%
90%
90%
70%
100%
70%
70%
70%
70%
70%
70%
70%
not covered
not covered
70%
70%
70% no deductible
70% no deductible
70% no deductible
70% no deductible
70%
70%
70%
80%
100%
80%
80%
80%
80%
$15 copay then 100%
$30 copay then 100%
$15 copay then 100%
$15 copay then 100%
100%
$15 copay then 100%
100%
100%
$15 copay then 100%
100%
$15 copay then 100%
80%
80%
80%
60%
100%
60%
60%
60%
60%
60%
60%
60%
not covered
not covered
60%
60%
60% no deductible
60% no deductible
60% no deductible
60% no deductible
60%
60%
60%
70%
100%
70%
70%
70%
70%
$15 copay then 100%
$30 copay then 100%
$15 copay then 100%
$15 copay then 100%
100%
$15 copay then 100%
100%
100%
$15 copay then 100%
100%
$15 copay then 100%
70%
70%
70%
50%
100%
50%
50%
50%
50%
50%
50%
50%
not covered
not covered
50%
50%
50% no deductible
50% no deductible
50% no deductible
50% no deductible
50%
50%
50%
90%
90%
$50 copay then 90%
90%
80%
80%
$50 copay then 70%
$15 copay then 100%
90%
70%
90%
70%
90%
70%
90%, 120 days per calendar year
90%, 120 days per calendar year
90%
90%
90%
70%
10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for
brand if generic is available; $60 max per prescription Retail or Mail Service.
If a brand name drug is prescribed and a generic is available, the maximum
coinsurance is $100 unless the physician has indicated "dispense as
written".Mail Service required after 90 days for maintenance medications.
1) EKG, chest x-ray, complete blood count, SMA 12, urinalysis.
2) Once per calendar year for covered persons within eligible groups
3) No coverage for facility charges during non-emergency use of emergency room; benefits cover professional
component only.
4) Office visit co-pays apply to cost of the office visit only.
5) All plans are grandfathered.
$50 copay then 80%
80%
70%
70%
$50 copay then 60%
$15 copay then 100%
80%
60%
80%
60%
80%
60%
80%, 120 days per calendar year
80%, 120 days per calendar year
80%
80%
80%
60%
$50 copay then 70%
70%
$50 copay then 50%
$15 copay then 100%
70%
50%
70%
50%
70%
50%
70%, 120 days per calendar year
70%, 120 days per calendar year
70%
70%
70%
50%
10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if
generic is available; $60 max per prescription Retail or Mail Service. If a brand
name drug is prescribed and a generic is available, the maximum coinsurance is
$100 unless the physician has indicated "dispense as written".Mail Service
required after 90 days for maintenance medications.
10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if
generic is available; $60 max per prescription Retail or Mail Service. If a brand
name drug is prescribed and a generic is available, the maximum coinsurance is
$100 unless the physician has indicated "dispense as written".Mail Service required
after 90 days for maintenance medications.
This is a summary. If there is a difference between this summary and the plan documents,
benefits will be paid in accordance with the plan documents.