| COVERAGE DESCRIPTION - PLAN HMO STANDARD |
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Copay Options: ($15/30/40/50) |
| Annual Deductible |
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$1,000 or $2,500 per person / $2,000 or $5,000 per family |
| Coinsurance |
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options for 50%, 40%,30%,20% |
| Maximum Annual Coinsurance Limit |
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No greater than $5,000 |
| Lifetime Maximum |
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Unlimited |
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| FACILITY BENEFITS |
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| Inpatient Services and Supplies (Subject to pre-approval) |
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$150/300/400/500 copay per day up to 5 days per admission |
| Inpatient Hospital: Semi-Private |
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Maximum copay $1,500/3,000/4,000/5,000 per year/per person |
| 365 days per year |
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| Rehabilitation Center Services |
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Subject to inpatient hospital copayment |
| (Subject to pre-approval) |
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Copayment will not apply if the admission is immediately preceded by a
hospital inpatient stay |
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| Emergency Room |
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Separate $100 copay |
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(waived if admitted, credited toward inpatient |
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admission, if admission occurs within 24 hours as a result of the
emergency) |
| Home Health Care (Subject to pre-approval) |
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Unlimited |
| Skilled Nursing (Subject to pre-approval) |
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Unlimited |
| Hospice Charges (Subject to pre-approval) |
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Unlimited |
| Mental/Nervous Health and Substance Abuse |
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| Outpatient (Subject to pre-approval) |
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$15/30/40/50 copay, maximum 20 visits per year |
| Inpatient (Subject to pre-approval) |
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$150/300/400/500 copay per day up to 5 days per admission |
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Maximum 30 inpatient 30 inpatient days per year (1 inpatient day may be
exchanged for 2 outpatient visits or partial hospital days); Maximum copay:
$1,500/3,000/4,000/5,000 per year/per person |
| Alcoholism |
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| Outpatient (Subject to pre-approval) |
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Same as above |
| Inpatient (Subject to pre-approval) |
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Same as above |
| PROVIDER BENEFITS |
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| Primary (Preventive) Care |
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$15/30/40/50 copay |
| well baby, routine physical exam, mammography, pap smears,
vaccinations and screenings |
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| Maternity Office Visits |
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$25 copay initial visit |
| Surgical - Outpatient and Inpatient |
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$15/30/40/50 copay (Outpatient only) |
| Therapy Services |
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| Inpatient basis only |
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$15/30/40/50 copay |
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Speech, physical, occupational and cognitive therapies covered for 60
day period per incident of illness or injury (Subject to pre-approval and copay) |
| Chelation, chemotherapy, dialysis, infusion and radiation |
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Unlimited (Subject to pre-approval and copay) |
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| OTHER SERVICES |
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| Prescription |
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50% coinsurance, for a prescription card, at carrier option |
| Durable Medical Equipment |
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$15/30/40/50 copay |
| (Subject to pre-approval) |
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| Blood/Blood Products/Processing |
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| Inpatient |
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Subject to inpatient copay |
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