|
BENEFIT
|
Tier I
HealthLink HMO Network
|
Tier II
HealthLink PPO Network
|
Tier III
Non-HealthLink
Providers
|
| Plan
Year Maximum |
Unlimited |
Unlimited |
$1,000,000 |
Lifetime
Maximum
|
Unlimited |
Unlimited |
$1,000,000 |
|
Annual Out-of-Pocket Max*
Per Individual enrollee
Per Family
|
$0
$0 |
$600
$1,200 |
$1,500
$3,500 |
Annual
Deductible
Must be satisfied for all services
|
$0
|
$200
Per Enrollee**
|
$300
Per Enrollee** |
| HOSPITAL
SERVICES |
| Inpatient
|
Full
coverage after $275 copayment per admission
|
90%
of network charges for covered services after $325 copayment per admission
|
80%
of U&C*** for covered services after $425 copayment per admission |
| Inpatient
Psychiatric |
Full coverage
after $275 copayment per admission up to 30 days per plan year |
90% of covered
services after $325 copayment per admission up to 30 days per plan
year
|
80%
of U&C for covered services after $425 copayment per admission
up to 30 days per plan year |
Inpatient
Alcohol and Substance Abuse
|
Full coverage
after $275 copayment per admission up to 10 days rehabilitation per
plan year |
90% of covered
services after $325 copayment per admission up to 10 days rehabilitation
per plan year |
80%
of U&C for covered services after $425 copayment per admission
up to 10 days rehabilitation per plan year |
|
Emergency Room
Waived if admitted
|
Full
coverage after $200 copayment
|
90%
for covered services after $200 copayment |
80%
of U&C for covered services after $200 copayment |
| Outpatient
Surgery
|
Full
coverage after $175 copayment
|
90% of network
charges after $175 copayment |
80% of U&C
for covered services after $175 copayment |
| Outpatient
Psychiatric and Substance Abuse
|
Full coverage
after $15 copayment up to 30 visits per plan year (additional 30 visits
for Autism)
|
90% of covered
services after $15 copayment up to 30 visits per plan year (additional
30 visits for Autism)
|
80% of U&C
for covered services after $15 copayment up to 30 visits per plan year
(additional 30 visits for Autism) |
| Diagnostic
Lab & X-Ray |
Full
coverage
|
90%
of network charges for covered services |
80%
of U&C for covered services |
| PHYSICIAN
AND OTHER PROFESSIONAL SERVICES |
| Physician
Office Visits |
Full
coverage after $15 copayment |
90%
of network charges for covered services
|
80%
of U&C for covered services |
| Specialist |
Full
coverage after $20 copayment |
90%
of network charges for covered services
|
80%
of U&C for covered services |
Preventive
Health Services
Including immunizations, allergy testing and treatment
|
Full
coverage after $15 copayment |
90%
of network charges for covered services
|
Not Covered
Under Tier III |
| Chiropractic
Care |
Full
coverage after $20 copayment up to 25 visits per plan year |
90%
of network charges for covered services up to 25 visits per plan year |
80%
of U&C for covered services up to 25 visits per plan year |
Well
Baby Care
|
Full
coverage |
90%
of network charges for covered services
|
Not Covered Under Tier III |
| OTHER
SERVICES |
Durable
Medical Eqpt
|
Full
coverage |
90%
of network charges for covered services |
80%
of U&C for covered services |
| Skilled
Nursing Facility |
Full
coverage |
90%
of network charges for covered services |
Not Covered
Under Tier III |
| Transplant
Coverage |
Full
coverage |
90%
of network charges for covered services |
Not Covered
Under Tier III |
| Home
Health Visits |
Full
coverage after $20 copayment |
90%
of network charges for covered services |
Not Covered
Under Tier III |
| Hearing
Exam and Aids |
Covered
up to $100 for exam(s) and up to $500 for aids every 3 years |
Covered
up to $100 for exam(s) and up to $500 - 90% of network charges for
covered services |
Not Covered Under Tier III |
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