|
|
| BENEFIT |
IN-NETWORK |
OUT-OF-NETWORK |
| Annual Deductible |
This plan features two separate medical deductibles: $500 per member for emergency and hospital inpatient/outpatient services; and $5,000 per member for other covered services. (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.) |
| Lifetime Maximum |
$5,000,000 per member |
Annual Out-of-Pocket Max.
(includes deductible) |
Both medical deductibles apply to satisfy a total of $5,000 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family) |
| Doctors' Office Visits |
Children: 4 office visits per year at $30 copay per visit; Adults: 2 office visits per year at $30 copay per visit (deductible waived) |
Children: 4 office visits per year; Adults: 2 office visits per year; 50% of negotiated fee plus all excess charges (deductible waived) |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
20% of negotiated fee for inpatient or surgical procedures only. You pay for other covered services until the out-of-pocket maximum is met, then plan pays 100% of negotiated fee. |
50% of negotiated fee, plus excess charges for covered inpatient or surgical procedures only. You pay for other covered services until out-of-pocket maximum is met. |
Hospital Inpatient
(Overnight Hospital Stays) |
20% of negotiated fee after $500 deductible |
All Charges except $650 per day |
Hospital Inpatient
(If You Don't Stay Overnight) |
20% of negotiated fee after $500 deductible |
All Charges except $380 per day |
| Emergency Room Services |
20% of negotiated fee after $500 deductible |
20% of customary and reasonable fees plus excess charges |
| Maternity |
Not Covered |
| Preventive Care |
Routine mammogram, Pap and PSA tests:
20% of negotiated fee (deductible waived)
Well Baby and Well Child (through age 6): 50% of negotiated fee (deductible waived)
HealthyCheck Centers:
$25/$75 copay for basic/premium screening (deductible waived) |
Routine mammogram, Pap and PSA tests:
50% of negotiated fee plus all excess charges (deductible waived)
Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges (deductible waived)
|
| Ambulance |
20% of negotiated fee |
50% of negotiated fee plus all charges in excess of negotiated fee and in excess of the plans $750 maximum payment per ground trip |
| Physical & Occupational Therapy; Chiropractic Services |
20% of negotiated fee, up to 12 visits per year |
All charges except $25 per visit, up to 12 visits per year |
| Accupunture/Accupressure |
All charges except $25 per visit, up to 24 visits per year |
| Prescription Drugs |
$10 copay generic; $30 copay brand-name
after $500 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self administered injectables, except insulin |
50% of drug limited fee schedule
and all excess charges plus the copay/coinsurance as stated for in-network benfits; subject to the annual $500 brand-name prescription drug deductible. |
|
|
Important Disclaimer: Answers and comments provided above
are general information, and are not intended to substitute for
informed professional medical, psychiatric, psychological, tax, legal,
investment, accounting, governmental, or other professional advice.
We do not endorse, and expressly disclaims liability for any product,
manufacturer, distributor, service, health plan, or service provider mentioned
or any opinion expressed in the website. Replies, comments, or information
gathered on BarricksInsurance.com
website may not be accurate but are intended to be helpful.