Other Benefit Summaries:

 

MEDICAL       DENTAL          LIFE          LTD

 

PPO Medical Plan - EBMS Administrators

January 1, 2004 - December 31, 2004

Information provided is in summary format.  Any difference between the summary provided and actual contract will be settled in favor of the contract.

In-Network

Non-Network
Network Contracted Beechstreet Medical Providers Non-contracted Beechstreet Medical Providers

Deductible

 $200 per Person/$600 per Family

Coinsurance

 80% after deductible 60% after deductible*

Out-of-Pocket Max

$1,000

Lifetime Maximum Benefit

 $1,000,000
Supplemental Accident 100% up to $300 max per person per accident

Office Visits

 80% after deductible 60% after deductible

Well Child Care

 80%

Diagnostic Imaging & Lab

 80% after deductible 60% after deductible
LabOne Program** 100%  

Ambulance

 80% after deductible 60% after deductible

Hospital Inpatient

 80% after deductible 60% after deductible

Emergency Room

 80% after deductible 60% after deductible

Maternity

 Paid the same as any other condition

Chiropractor Services - 35 visit max/yr

80% to $25 max per visit

$100 X-ray max per year

Rehabilitation Therapy:

  

     Inpatient - 15 day max/yr

80% 60%

     Outpatient - $2,000 max/yr

80% 60%

     Outpatient/Inpatient 

     Maximums

$20,000 per calendar year

$100,000 lifetime maximum

Mental/Nervous Treatment:

  

     Inpatient - 5 day max/yr

 50% after deductible

     Outpatient - 15 visit max/yr

50% after deductible

Chemical Dependency

80% after deductible 60% after deductible
Transplants - $500,000 lifetime max 80% after deductible 60% after deductible

Retail Prescriptions   

(Participating Pharmacies)

Generic:  $10 copay

Formulary Brand:  $25 copay

Non-Formulary Brand:  $40 copay

     RX Dosages

 30 day supply

Mail Order Prescriptions

Generic:  $20 copay

Formulary Brand:  $50 copay

Non-Formulary Brand:  $80 copay

     RX Dosages

 90 day supply

*Plus any amounts above allowable charge.

**The LabOne Program is an enhanced benefit to your current health insurance plan.  If your physician(s) order lab work for you (example:  throat culture, urinalysis, blood draw, Pap Smear, etc.), they should collect your specimens and call LabOne for pick up at 1-800-646-7788.  Your physician may charge a collections fee which is subject your deductible and coinsurance.  However, you should not be billed for lab testing (Plan benefit is 100%, no deductible).  Call LabOne for collection sites in your area or for more information on how to use the LabOne benefit.


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