|
<br />.~
<br />\ )if/( -0 '\
<br />
<br />p~~
<br />
<br />"I1YSIClAN SERVICES
<br />
<br />'.If,e,.;,;"
<br />!-'r ar.: indudjn~:
<br />Rourin~ krttninp
<br />
<br />~-.~..
<br />. ~.
<br />
<br />~
<br />
<br />ldEDlCAPREMIER
<br />612f94S-8000
<br />
<br />Tier I Servj,ccs
<br />(s,r";mrf'(rl,,,Jfr,,,,,p,.,rtrttJ
<br />J, ,.", /in,p".,,'d ,m,..,ry (Iut
<br />,u.ie}
<br />
<br />SIOcof".1Y
<br />
<br />100%
<br />
<br />T,~, 2s.c.",icc.l
<br />(!wTvim ,"",.,t! jrP"I (I' 'i'm~
<br />~.Kif-nifm4/~~.n,~~~)
<br />
<br />s:!s cop..y
<br />
<br />100%
<br />
<br />~
<br />
<br />~
<br />
<br />FORI1SJPREFERREDl
<br />6121138-5600
<br />
<br />Authoriud Scrvicq
<br />(f.t.""Ul1 'tin,.,.ti film., .,mo,,'
<br />by .r-'" ',J1f'W"J /'rrfnmlJ
<br />~ r~~')' tlIft dlnir)
<br />~~ 0 (opay
<br />
<br />IOO~u
<br />
<br />RoUlin~ ph~ic.al
<br />cum,
<br />I'rn<c'Rlivc eye and
<br />hearin(t c:u.ms
<br />Immuni:r.:uions
<br />
<br />\X'dl child cue
<br />Pre and posmau.l
<br />tnatc:rniry care:
<br />Deliverylsu'lC'f)' (physician
<br />ch"'l!')
<br />Outpatimt (wnc da)') su1Jc'1)'
<br />
<br />Ur~cnr Care
<br />Outpatient menw health
<br />
<br />Ourparic'ft( chemical
<br />d<p<nd<nq
<br />
<br />OliropBCtic care
<br />
<br />Physical. speech. oc.cupational
<br />thccapy ,
<br />I Home hc:aJth care
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />100%
<br />100%
<br />
<br />90%
<br />
<br />90% sdeaed outpatient
<br />w,@:et}'
<br />510 copay
<br />S 1 0 corny per indo hour or S5
<br />copay pcr group hour; 40
<br />hours pc' member per rear
<br />SIO copay pcr indo hour or S5
<br />copay pet IrouP hour; 20 viiiu
<br />pcr member per year
<br />SIO """Y
<br />
<br />SIO col"Y
<br />
<br />) 00%; alternative to hospicaJ
<br />confinement; 90% wiled care
<br />in.home
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />100%
<br />100%
<br />
<br />80%
<br />
<br />80% ~1C'Ctcd ourp2liC'nt
<br />sUIJcI')'
<br />S25 cora"
<br />$10 copay p" incl. hour or SS
<br />copa)' per ,:roup hour. 40
<br />houn pcr mC'm~r per )'nf
<br />SID COp:lY per ind. hour or S 5
<br />copay pet group hour. 20 vilia
<br />pcr mcmbn pet year
<br />S 1 0 copay: 30 visit maximum; ~
<br />must U,Se ChiroCare nnwork
<br />S25 COI"Y
<br />
<br />J 00%; a1ternativc 10 hospiuJ
<br />confinlem~r. 80% akillcd care
<br />in.homc
<br />
<br />100%
<br />
<br />S 10 cora,. thcn 90%
<br />
<br />100%
<br />100% lhrouFh a~C' 6
<br />100%
<br />
<br />90%
<br />
<br />90% Kleacd outpatient
<br />lur[:cf)'
<br />SIOcopa)'
<br />80% (1m 10 houn; additional
<br />30 houn require aumorization
<br />
<br />90%; up to 130 hours
<br />
<br />SIO "'I"Y
<br />
<br />$10 copay
<br />
<br />90% to otu-of.pocket
<br />maximum
<br />
<br />Unauthoriud Sc-rv.cu
<br />((h.'~f,uru.ri)
<br />
<br />5~ after d~uCtibl(
<br />
<br />50% aftcl deductihle; S300
<br />max. co~rC'd nrcnKS per year
<br />50% :lflct dcducliblc-; S300
<br />max. COVC'led C'll~nsn per year
<br />;0% a(u~l dC'ductiblc
<br />
<br />100%
<br />
<br />Joo% thlOugh il(:C 6
<br />
<br />r,cn:ual: 100%; Postnatal:
<br />;0% .FtC! deduetiblc
<br />
<br />50% after deduaiblt
<br />
<br />;0% after deductible
<br />
<br />~O% ancr deductible
<br />
<br />50% mer deduCtible fint 10
<br />hours: addirional30 houn
<br />r<<luiu- authoritation
<br />
<br />50% .nrr deduaiblC' up to
<br />J 30 noun
<br />
<br />50% after dcduaiblr
<br />
<br />50% aftrr deduaible
<br />
<br />50% after deduCtible
<br />
<br />\ ,/
<br />
<br />~
<br />~~lM:~~:~,~W
<br />
<br />(Sn1-irn Nldt w "rtI",J (,om .,
<br />Jiwr:W" ,)11'11' Jnipw.;; G,.ur
<br />Ht4Uh ,TiIlUl,,! (1m rJinill
<br />
<br />510 copar rer vi,il
<br />
<br />100%
<br />
<br />~.~. .
<br />. ~ "
<br />
<br />
<br />, ~
<br />
<br />
<br />~
<br />
<br />(S,l1"'f'1 MIU' W "UII.,.J frlJlrl II'
<br />Ji,,(uli ~ ,,,-N' tk$'!IUItJ 8Jllt
<br />~~!.~':' (,,,, rlm!!.!.-
<br />5 J 0 copa~'
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />
<br />100%
<br />100%
<br />100%
<br />
<br />100%
<br />100%
<br />100%
<br />
<br />90%
<br />
<br />90"- ,deaed outpatient
<br />"'~'l'
<br />$10 cop'Y
<br />$ 1 5 copay houri 1.20; $20
<br />copay houn 2 J-40
<br />
<br />S10 copay'per vUlt; up to 40
<br />houn pet)'C"
<br />
<br />SIO cop.oy pet viUr. ..f,m!
<br />wrcd .
<br />SIO copay pn; visit
<br />
<br />l~ if alrCTO.ti~ to
<br />inplltient hospital; 90% all
<br />od>er
<br />
<br />90%
<br />
<br />90% hospitaJ-b~
<br />oUlpauenr Kf'Vica
<br />510 copay
<br />80% lint)O houn; 75%
<br />next 30 houn
<br />
<br />90%; up to 40 hours
<br />
<br />5 10 copay offi<< vi,ir,
<br />90% thcnpy services
<br />S J 0 copay office visit;
<br />9Mb therapy SCMcc:s
<br />_ ) 00% if abernaun to
<br />inpatient hospirali
<br />90% aU other
<br />
<br />HOSPITAL
<br />General (includes matemi
<br />M....,] b..Ith
<br />
<br />
<br />, 00cnUaI depend.ncy
<br />
<br />I
<br />! Emc.rgcnc:y Room
<br />
<br />lIO%
<br />
<br />90%, 30 cbys pcr member per _
<br />c:a.lendar)Uf. Must' UK' UBS. ~
<br />
<br />Manbcr pays 20% up ro
<br />S250; 73 chys pet member per
<br />calendar . Must use UBS.
<br />
<br />S40 cop>y; w.ived if admined
<br />within 24 houri
<br />
<br />80%
<br />
<br />100%
<br />90%, 30 chys per caI.ndar
<br />,.."
<br />~ ~; 73 chys per a1end"
<br />
<br />50% aner deductible
<br />50% meT deduerible: 30 chys
<br />r ca.lendar yttr
<br />500% mu dcd.uctiblr; 73 days
<br />per calcndar ynr .
<br />
<br />90%
<br />
<br />~ $40 cop'To waived if admined SO% mer deductible
<br />
<br />50% after deductible
<br />
<br />100%
<br />90%: 30 chys per alendar
<br />
<br />90%, 73 chys per Iifetim.
<br />
<br />S40cop.oy;
<br />waived if admitted
<br />80%
<br />
<br />100%
<br />90%, 30 d.ys per calendar
<br />,...r
<br />90%, 73 chys pcr akndar
<br />ynr
<br />
<br />S40 copay;
<br />waivtd if admined
<br />80%
<br />
<br />100%
<br />
<br />100%
<br />
<br />90% to out-oF-pocket
<br />maximum
<br />
<br />50% after deduaible
<br />
<br />100%
<br />
<br />I Ot2J contneepuvcs
<br />
<br />I
<br />
<br />j Pto&thttie. dw:able: medical
<br />j equipment
<br />I Acdd...,.rebced cknal
<br />I
<br />!
<br />i EY'CWCat
<br />\.
<br />i Allcq;y uea unent
<br />,
<br />
<br />'OTHER
<br />Out~f area cme:rgmc:y
<br />benefitS
<br />Out-of.pocket maximum
<br />
<br />, Dcduaible: {or other services
<br />; and supplies (if applicabld
<br />j tifmme medical maximum
<br />In.!)
<br />1 T WlSplanu covered
<br />.
<br />
<br />. Cosmetic sutp:ry
<br />
<br />1':>\ "c.. ~
<br />~~,\
<br />e
<br />
<br />57 copay per prescription or
<br />rdiD
<br />
<br />57 copa)' per ptcsc:riprion or
<br />refill: 3 month supply
<br />
<br />90%
<br />
<br />I'. 80% if within 6 months; no
<br />. coverage after 6 months
<br />
<br />I:.. Discounu available through
<br />; sdccted vendon
<br />1:- SIOcopay(ortcning; I~
<br />0." for injections
<br />I'
<br />I 80% cove"!!,,. S500
<br />, out-of.pockct maximum
<br />S 1.000 per ;nc!;vid..J1
<br />52.000 per family combined
<br />with Tier 2
<br />N/A
<br />
<br />Unlimited
<br />
<br />Trc.a~ u an~' other illness
<br />
<br />lGdner. hc::art.lung. heartl
<br />lung..linr. cornea. and
<br />specihed bone: marro\\".
<br />Subjca to plan limirJtions and
<br />medical necc:ssil)'.
<br />
<br />NOt COVC'rcd unlcu medic:aJly
<br />DCCCSSU)' .
<br />
<br />57 cop')' per prescription Of
<br />refill
<br />
<br />$7 copay per prescription or
<br />refill: 3 month supply
<br />
<br />70%
<br />
<br />70% cover:age if within 6
<br />mos.; no coverage mer 6 mas.
<br />
<br />Discounu availabk through
<br />selected vmdon
<br />$25 copay for resting; 1009&
<br />for injections
<br />
<br />80% COV<ng. to S500
<br />out.of.poc:ktr maximum
<br />S2.OOO pcr individuall
<br />$4.000 per (amily combined
<br />with Tier 1
<br />N/A
<br />
<br />Unlimircd
<br />
<br />T rClllcd 111 any other illness
<br />
<br />Kidn~'. hean,iunt:.. hcanl
<br />lunt:.liver. cornea, and
<br />spttilicd bone marrow.
<br />Subject to plan Jimi~ations and
<br />medical ncecssit),.
<br />
<br />Not covered unless mcdicaJly
<br />neccual)'.
<br />
<br />\ 'Sa ~.'""\ ~
<br />'$l:3\.CCI
<br />
<br />SIO col"yIS7 (g.neric b""d)
<br />mail order 90.-day supply.
<br />J copay
<br />SIO "'l"ylS7 (g....ric b..nd)
<br />3 month supply
<br />
<br />90%
<br />
<br />90%
<br />
<br />Not coY'Ued
<br />
<br />SJO copa)' for office viJit;
<br />90% all other scrvices
<br />
<br />80%
<br />
<br />51,000 per indi\idualJ
<br />S2,OOO pcr (,milr
<br />
<br />N/A
<br />
<br />S2.000.000
<br />
<br />T l"C'a~ed as any other iUnm
<br />
<br />lunp. liver. heart. hcartllun~.
<br />kidney. cornea, specified bone
<br />marrcw.'. Subject to plan
<br />limitariom and mcdic.a.l
<br />necnsi~y.
<br />
<br />Not covered unless medially
<br />h<<cssa~'.
<br />
<br />~ tt. --:r. ~
<br />
<br />I.,
<br />
<br />S I 0 cop.orlS7 (g....ric b..nd)
<br />mail order 9O.-day supply.
<br />I cop.oy
<br />S I 0 cop.oylS7 (gcn.ne h..nd)
<br />mail order 9O-dll)' supply.
<br />I col"r
<br />50% anu deduCtible
<br />
<br />50% after deduaible
<br />
<br />NOI cove:mi
<br />
<br />525 copay for offi<< vu.it;
<br />50% aU other services
<br />
<br />50% .ncr deduCtible
<br />
<br />53.000 pa individuaU
<br />S6.000 pcr (,milr
<br />
<br />$200 (per calcnd" ynr)
<br />where applicable
<br />
<br />S2.000,000
<br />
<br />50% aher dcduaibk
<br />
<br />Lunp.lh-cr. hc.an. hcanllung.
<br />kidnc-y. cornea. specified bonc
<br />marrow. Subjm to plan
<br />limitations and medial
<br />nc:ccssiry.
<br />
<br />1':01 eO\-rred unless medically
<br />necosary"
<br />
<br />\ '-'. q.. ~~
<br />Io\"',~~
<br />
<br />Q \J C "\ -e.
<br />
<br />57 copay per preKription
<br />.rrefill
<br />
<br />57 per 3 month supply
<br />
<br />90% COV<ng'
<br />
<br />90% if within G months; no
<br />coverage altcr 6 months
<br />
<br />Low member prices al Group
<br />Haith 0 rial d enu
<br />
<br />$10 coplr for teSting; J 00%
<br />for injccOons
<br />
<br />80% to $1.500; then 100%
<br />
<br />51.000 per individuall
<br />$2.000 per family
<br />
<br />N/A
<br />
<br />Unlimiffi:!
<br />
<br />T reared as any other illness
<br />
<br />I..ivc:r. heart. heanllung.. lunF:.
<br />COtnCI. kidnC')'. specified
<br />boM marrow. Subject to
<br />plan limitations and medical
<br />neaait)..
<br />
<br />Nor covered unles.s medially
<br />ncccssaty.
<br />
<br />t'~:\
<br />Sy,.lD').
<br />
<br />S7 copay form war')":
<br />$ 1 0 copay nonformulary;
<br />(34 day or 100 unit supply)
<br />
<br />$7 cop2y formula!')'i S I 0
<br />cop..y non(onnulal),,:
<br />3 month supply
<br />
<br />90%
<br />
<br />90% if within 6 months
<br />ofin;ury. No COVUll!C
<br />anu 6 months.
<br />
<br />EycwcaJ' discounu for
<br />memben
<br />
<br />5 J 0 co~y for testing;
<br />100% fOf in' ections
<br />
<br />In-nerwork benefiu
<br />
<br />51.000 per individuall
<br />S2.OOO p" family
<br />
<br />N/A
<br />
<br />Unlimired
<br />
<br />Treated as 1I1Y other iIIoos
<br />
<br />Hean. hean/lunJ;.lunf:.livrr.
<br />pancreas and specified bone:
<br />marrow.lcidnC"o\ cornea. and
<br />skin. Subject;o plan
<br />limilarions and medical
<br />necCSJi~',
<br />
<br />Not CO\"a"rd unlelS mediall)'
<br />nC'CC$S:ll)".
<br />
<br />\I.>>\'\~
<br />-;~~..."
<br />
|