|
Medical Plan -
PacifiCare
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 |
801173 |
|
Network |
PacifiCare Providers
|
|
Deductible |
None |
|
Out-of-Pocket Max |
$1,500
Individual/
$3,000
Family
|
|
Maximum
Benefit |
Unlimited |
|
Office
Visits |
$15 Copay
|
|
Preventive Care |
$15 Copay
|
|
Lab
Work |
100% |
|
Ambulance
|
100% |
|
Hospital Inpatient |
$100
Copay/Admission |
|
Emergency
Room |
$50 Copay
plus 10% (waived if admitted)
|
|
Chiropractic |
$15
Copay |
|
Rehabilitation:
|
|
|
Inpatient**- 15 days/yr
|
$100
Copay/Admission |
|
Outpatient
|
$15
Copay |
|
Mental Nervous:
|
|
|
Inpatient- 20 days/yr
|
$100
Copay/Admission, then 80% |
|
Outpatient - 30 visits/yr
|
$30
Copay |
|
Chemical Dependency:
|
|
|
Inpatient - 45 days/yr
|
100% |
|
Outpatient - 45 visits/yr
|
$15
Copay |
|
Vision - one
exam/yr |
$15 Copay
See the self-funded NBN
Vision Plan Summary offered by the
Seattle
Public Schools to all eligible employees. |
|
Hearing - one exam/yr |
$15 Copay |
|
Retail Prescriptions
(Par
Pharmacies)
|
Generic: $15 Copay
Formulary Brand: $25 Copay
Non-Formulary Brand: $40 Copay
|
|
RX Supply - Retail |
30-day supply |
|
Mail
Order Prescriptions |
Generic: $30 Copay
Formulary Brand: $50 Copay
Non-Formulary Brand: $80 Copay
|
|
RX Supply - Mail Order |
90-day supply |
|
Notes |
*No benefits are payable for services outside of the
PacificCare Managed Care Network unless it is a
medical emergency. Also, referrals are generally
required from your Primary Care Provider (PCP) for
care outside your PCP. |
