BENEFIT
DESCRIPTION |
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
|
Lifetime Maximum Benefit (LTM): |
$1,000,000.00 per person |
|
Contract Allowance: |
Based on PPO fee schedule |
Based on MAP allowance |
|
Calendar Year Deductible
(CYD) |
|
|
|
Individual Maximum |
$300 |
$500 |
|
Family Maximum |
$900 |
$1500 |
|
Physician Expenses: |
|
|
|
Office visits |
$15 copay* |
50% of allowance,
after CYD |
|
Adult Wellness (routine
physical including related testing) |
$15 copay*
(max $750 per CY) |
50% of allowance deductible
waived
(max $750 per CY) |
|
Maternity-office visits &
delivery |
$15 copay* first visit,
then 80% fee schedule |
50% of allowance,
after CYD |
|
Well child care (birth to
age 16, 18 visits) |
$15 copay* |
50% of allowance deductible
waived |
|
Wellness Colonoscopy - Beginning at age 50 – see plan for details |
100% of fee schedule(Not subject to Wellness Max of $750) |
50% of allowance after CYD (Not subject to Wellness Max of $750 ) |
|
Lab, X-Ray & Diagnostic
Testing: |
80% of fee schedule, after
CYD Deductible Waived-Laboratory tests |
50% of allowance,
after CYD |
|
Hospital Expenses
(including maternity) |
|
|
|
Inpatient - including
physician visits |
80% of fee schedule, after
CYD |
50% of allowance,
after CYD and PAD |
|
Nursery Care for
Well Newborns |
80% of fee schedule, after
CYD |
50% of allowance,
Deductible Waived |
|
Outpatient Surgury
(Hospital or Surgical Center) |
80% of fee schedule, after
CYD |
50% of allowance,
after CYD |
|
Per Admission Deductible
(PAD) |
None |
$500 per admission |
|
Emergency Room/
Hospital care: |
$50 ER deductible,
after CYD; then 80%
of fee schedule (ER Deductible waived if admitted) |
$50 ER deductible,
after CYD; then 50%
of allowance (ER Deductible waived if admitted), CYD and PAD
applies if admitted |
|
Other Expenses |
|
|
|
Home HealthCare |
80% of fee schedule, after
CYD
($3,000 CY max) |
50% of allowance,
after CYD
($3,000 CY max) |
|
DME |
80% of fee schedule, after
CYD |
50% of allowance,
after CYD |
|
Physical, Speech, Cardiac,
Occupational Therapy |
80% of fee schedule, after
CYD
($10,000 CY max) |
50% of allowance,
after CYD
($10,000 CY max) |
|
Ambulance Services
(Deductible waived for accident related services) |
80% of allowance deductible
waived |
80% of allowance deductible
waived |
|
Skilled Nursing Facility |
80% of allowance,
after CYD
(90 days per CY) |
50% of allowance,
after CYD
(90 days per CY) |
|
Hospice |
100% of allowance
deductible waived ($7,500 LTM) |
100% of allowance
deductible waived ($7,500 LTM) |
|
Ambulance
Services
(Deductible waived for accident related services)
|
80% of allowance, deductible waived
|
80% of allowance, deductible waived
|
|
Mental and Nervous |
|
|
|
Inpatient |
80% of fee schedule, after
CYD
(30 days/visits per CY) |
50% of allowance,
after CYD and PAD
(30 days/visits per CY) |
|
Outpatient |
$15 copay *
(45 visits per CY) |
50% of allowance,
after CYD
(45 visits per CY) |
|
Alcohol and Drugs: |
|
|
|
Inpatient |
80% of fee schedule, after
CYD (30 days/visits per CYD) |
50% of allowance,
after CYD and
PAD (30 days/visits per CYD) |
|
Outpatient |
$15 copay* (45 visits per
CY) |
50% of allowance,
after CYD (45 visits per CY) |
|
|
|
|
|
Out of Pocket Coinsurance
Maximums**: |
Excludes Deductibles and
Copayments |
|
Individual |
$2500 |
|
Family - Aggregate |
$5000 |
|
Organ Transplant |
|
|
|
Covered for heart,
heart-lung, liver lung, kidney, cornea and bone marrow transplants |
80% of fee schedule, after
CYD |
50% of allowance, after CTD
and PAD |
|
Dependent Children: |
Covered through the end of the calendar year in which child reaches age 19;
or age 25, if the child is dependent upon certificate holder for support and the child is either living at home
or a full time or part time student. After age 25 to continue as an overage dependent thru age 30 the child must
be unmarried, no dependents of their own, Florida Resident, full or part time student, does not have other coverage
and not entitled to social security. |
|
(Applies to All Plans) |
