|
Basic PPO
Medical
Plan - KPS Health Plans
October 1, 2003
- September 30, 2004 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
Policy
Number |
22165 |
|
|
Participating |
Non-Participating |
|
PPO
Network |
KPS/First Choice/Multiplan
Providers |
Any Other Licensed Provider |
|
Deductible |
$200
Individual/$600 Family |
|
Coinsurance |
80% |
70% |
|
Out-of-Pocket Limit - (does not include deductible or
copays |
$1,500
Individual/$3,000
Family |
$3,000
Individual/$6,000
Family |
|
Maximum
Benefit |
$5,000,000 |
|
Office
Visits |
$20 copay |
$25 copay |
|
Preventive
Care - $200/yr; well-baby care (to age 3) $500/yr |
100% |
70% |
|
Lab
Work (Outpatient) |
80% after deductible |
70% after deductible |
|
Ambulance |
80% after deductible |
70% after deductible |
|
Hospital
Inpatient* |
$150 copay/day to $450
max, then 80% after deductible |
$150 copay/day to $450
max, then 70% after deductible |
|
Emergency
Room |
$75 copay (waived if
admitted) |
|
Maternity |
Paid
as illness |
|
Outpatient
Rehabilitative Therapy
|
80% after deductible |
70% after deductible |
|
Inpatient
Rehabilitative Therapy- 120 days/yr |
$50 copay/day to $150
max, then 80% after deductible |
$50 copay/day to $150
max, then 70% after deductible |
|
Chiropractic |
$20 copay |
$25 copay |
|
Mental
Health |
|
|
Inpatient* |
$150 copay/day to $450
max, then 80% after deductible |
$150 copay/day to $450
max, then 70% after deductible |
|
Outpatient -
25 visits/yr |
80% after deductible |
70% after deductible |
|
Chemical Dependency: |
$11,285 maximum in 24 month period
|
|
Inpatient* |
$150 copay/day to $450
max, then 80% after deductible |
$150 copay/day to $450
max, then 70% after deductible |
|
Outpatient
|
80%
after deductible |
70% after deductible |
|
Retail Prescriptions
(Participating
Pharmacies)
|
Generic:
$7 copay
Preferred
Brand: $20 copay
Non-Preferred
Brand:
$35 copay
|
No Benefits |
|
Supply Limit |
30-day supply** |
No Benefits |
|
Mail Order
Prescriptions through Walgreens |
Generic:
$7 copay
Preferred
Brand: $20 copay
Non-Preferred
Brand:
$35 copay
|
No Benefits |
|
Supply Limit |
30-day supply** |
No Benefits |
|
Vision
Benefit |
None. See the self-funded NBN
Vision Plan Summary offered by the Seattle Public
Schools to all eligible employees. |
|
Hearing/Audio Benefit |
80% after deductible up to $125/yr |
|
Notes |
* Pre-Authorization required for inpatient hospital
admissions.
**Generic and certain maintenance drugs approved by KPS Health Plan, may be dispensed on a 3-month supply,
subject to 2 copayments. |
