| Benefit Description |
Within Physician Team |
Within Peoples Health Network
|
Out-of-Network |
| INPATIENT CARE |
| Inpatient Hospital Care |
$0 |
$150/day (days 1-3) |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Inpatient Mental Health Care |
$0 |
$0 |
Days 1-60: initial deductible of $1,024
Days 61-90: $256
Days 91-150: $512 |
| Skilled Nursing Facility |
$0 days 1-20;$50/day 21+ days |
| Home Health Care |
$0 |
10% ($500 OOP max) |
20% |
| OUTPATIENT CARE |
| PCP Office Visit |
$5 |
$25 |
20% |
| Specialist Office Visit(includes: chiropractic podiatry services) |
$10 |
$25 |
20% |
| Outpatient Mental Health / Substance Abuse Care |
$0 for visit 1-20; 50% of Medicare approved amounts for 21 and beyond visits |
20% |
| Outpatient Surgery |
$0 |
$150 |
20% |
Emergency Care
(waived if admitted) |
$50 |
$50 |
$50 |
| Ambulance Service |
$0 |
$0 |
$50 |
Urgently Needed Care
(within U.S.) |
$10 |
| Urgently Needed Care(outside of U.S.) |
$50 |
| Outpatient Rehabilitation Services(Includes: Occupational, Physical and Speech Therapy) |
$0 (Medicare limits apply) |
$0 (Medicare limits apply) |
20% (Medicare limits apply) |
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES |
| Durable Medical Equipment |
5% |
10% |
20% |
| Infusion Therapy |
$0 |
$0 |
20% |
| Prosthetic Devices |
5% |
20% |
20% |
| Diabetes Self-Monitoring Training and Supplies |
$0 |
$0 |
20% |
| Diagnostic Tests, X-Rays and Lab Services |
$0 |
$0 |
20% |
| PREVENTIVE SERVICES |
| Bone Mass Measurement |
$0 |
$0 |
20% |
| Colorectal Screening Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Immunizations |
$0 |
$0 |
20% |
| Mammograms |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Pap Smears and Pelvic Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Prostate Cancer Screening Exams |
$0 (1st exam) $5 for additional exams; unlimited |
$0 (1st exam) $5 for additional exams; unlimited |
20% |
| Routine Physical Exams |
$5 |
Not Covered |
Not Covered |
| TRANSPORTATION |
| Transportation |
$5 per trip, up to 12 one way trips |
Not Covered |
| ADDITIONAL BENEFITS |
| Dental Services |
$0 for selected preventive dental service including oral exam, cleaning and dental x-rays. (Annual Max of $1000 applies) $50 deductible for comprehensive coverage. |
| Hearing Services |
100% for routine hearing exams $10 for each Medicare covered diagnostic hearing exam |
100% for routine hearing exams / 20% for each Medicare covered diagnostic hearing exam |
| Vision Services |
$15 for routine exam (1 per year); $0 (for 1 pair of glasses or contact lenses per year) |
100% for routine hearing exams / 20% for each Medicare covered diagnostic hearing exam |
| Health Club Membership |
Health Club Membership
(including fitness classes) |
Not Covered |
| Health/Wellness Education |
Nutritional Training, Newsletter,Disease Management |
Not Covered |
| PHARMACY COVERAGE (PART D) |
| Generic Drugs |
$0 for a 30-day supply
$0 for a 90-day supply (retail or mail order) |
| Preferred Brand-Name Drugs |
$20 for a 30-day supply
$40 for a 90-day supply (retail or mail order) |
| Non-Preferred Brand-Name Drugs |
$40 for a 30-day supply
$80 for a 90-day supply (retail or mail order)
|
| Specialty Drugs |
20% for a 30-day supply
20% for a 90-day supply (retail or mail order) |
Please note:
This grid is merely an overview and should not be used as a replacement for the Summary of Benefits or Evidence of Coverage. |
Page content last updated: 07-01-08