2005/06/15 Council Agenda Packet

PPO Medical Plan Summary For January 1, 2006 (This document is for illustrative purposes only. It is not an SPD) 05/23/05 Services .• Plan Lifetime Benefit Maximum $2,000,000 Calendar Year Deductible til RX Out of Pocket Maximum Per Individual $300 Per Family $600 Out -of -Pocket Maximum (co pays do not apply to out of pocket maximum) Retail out -of -network - Per Individual $750 ($1,500 out of network) -Per Family $1,500 ($3,000 out of network) Office Visits $20 co pay then 100% (deductible waived) Lab & X -Ray Services 90% Preventive Care $20 co pay then 100%, deductible waived. Limited to $200 per person per calendar year. Includes wellness exams, routine physicals, immunizations and ob/gyn visits, and related tests Chiropractic (no out of network benefit) $20 cc pay then 80%. 24 visit maximum per calendar year. Hospital Treatment (Semi -private room and board) In Network $100 co pay then 90% Out of Network $200 co pay then 80% Outpatient Surgery In Network $100 co pay then 90% Out of Network $100 co pay then 60% Organ Transplants ($250,000 lifetime maximum) 90% (12 month wait) Rehabilitation ($30,000 annual Max.) -Inpatient $100 cc pay then 90% -Outpatient (12 visits each for Speech, Occupational and Physical 90% Therapy per calendar year) Emergency Room $100 co pay (waived if admitted) then 90% Mental Health- -Inpatient $100 cc pay then 80%, limited to 2 days per calendar year -Outpatient $20 co pay then 80%, limited to 20 visits per year Chemical Dependency** ($10,000 max. every 2 calendar years) -Outpatient treatment $20 co pay then 90% -Inpatient treatment $100 co pay then 80% TMJ ** ($1,000 annual benefit, $5,000 lifetime) $20 co pay then 80% Skilled Nursing (90 days per calendar year) 90% Home Health** (130 visits per calendar year) 90% Hospice" (limited to 6 months per calendar year) 90% Out of area benefits Same level of benefits as in -network Out of Network Benefits 60% benefit up to allowed amounts plus applicable co pays and deductible, unless otherwise stated. -- i nese services ao not accrue towards the out of pocket maximum (1) L;alenaar year aeauctiDle applies toward out-ot-pocket max DrugsPrescripton RX Out of Pocket Maximum $1,000/$2,000 then benefit increases to 100% Retail (in -network) 80% benefit for retail and selected OTC medications with a $50 out-of-pocket maximum per script - (one month supply) Birth Control Contraceptives will n be covered Retail out -of -network No out of network benefit 80% plus additonal 5% discount with a $50 out-of-pocket maximum per script Mail Order to a 3 month supply