Plan Brochure

BENEFIT DESCRIPTION

YOU PAY

In-Network

Out-of-Network

Preventive Care

Annual Routine Physical Exam (age 3 or older)

Nothing

50% after deductible is met*

Adult Routine Immunizations & Tests

Nothing

50% after deductible is met*

Well Child Care (through age 2)

Nothing

50% after deductible is met*

Routine Immunizations (through age 21)

Nothing

50% after deductible is met*

Inpatient Hospital Care (precertification required)

Maternity

20% after deductible is met

50% after deductible is met*

Medical/Surgery

Room and Board
Other Services and Supplies

20% after deductible is met

50% after deductible is met*

Mental Health/Substance Abuse

Room & Board Other Services and Supplies

20% after deductible is met

50% after deductible is met*

Outpatient Hospital Care

Medical/surgical

20% after deductible is met

50% after deductible is met*

Emergency Medical

20% after deductible is met

20% after deductible is met*

Chiropractic Care

Initial office visit and 12 office visits per calendar year when rendered on the same day as covered manipulations

20% after deductible is met

50% after deductible is met*

Manipulations (12 per calendar year)

20% after deductible is met

50% after deductible is met*

Physician Care

Office visits

20% after deductible is met

50% after deductible is met*

X-rays, other diagnostic services

20% after deductible is met

50% after deductible is met*

Laboratory Services

 20% after deductible is met

 50% after deductible is met*

Maternity Care (complete)

20% after deductible is met

50% after deductible is met*

Accidental Injury (nonsurgical care, simple laceration repair and immobilization of a sprain, strain, or fracture)

20% after deductible is met

50% after deductible is met*

Surgery

20% after deductible is met

50% after deductible is met*

Mental Health and Substance
Abuse Care:

   Office visit

20% after deductible is met

50% after deductible is met*

   Other diagnostic services

20% after deductible is met

50% after deductible is met*

   Laboratory Services

20% after deductible is met

 50% after deductible is met*

Prescription Drugs
This is a mandatory generic program

Network

Non-Network

Retail Pharmacy

1st and 2nd fill:
$10 of generic cost (after deductible is met)
$40 of Formulary brand cost (after deductible is met)
$60 of Non-Formulary brand cost (after deductible is met)

Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS/Caremark Pharmacy or Longs Drugs through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased.

Full cost at time of purchase
50% after deductible is met*

Mail Order Program

90-day supply: $20 generic/$80 Formulary brand/$120 Non-Formulary brand (after deductible is met)

Specialty drugs (requires prior approval)

• Caremark Specialty Pharmacy Mail Order:

• 30-day supply: $200 (after deductible is met)
• 90-day supply: $400 (after deductible is met)

Catastrophic Limits

Medical/Surgical/Mental health and substance abuse care

You pay nothing after coinsurance expenses total:

• $6,000 for a Self Only enrollment for services of In-Network providers/facilities.
• $12,000 for a Self and Family enrollment for services of In-Network providers/facilities
• $12,000 for a Self Only enrollment for services of Out-of-network providers/facilities.
• $24,000 for a Self and Family enrollment for services of Out-of-network providers/facilities

You pay nothing for covered prescription drugs (includes specialty drugs) after copayment amounts for prescription drugs purchased at a network retail pharmacy, Caremark mail order pharmacy or through Maintenance Choice Program total $6,000 for a Self Only enrollment or $12,000 for a Self and Family enrollment.

*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount.