WEBT

 

SUMMARY OF MEDICAL BENEFITS

 

Medical Base Plan

PLAN 1

PLAN 2

PLAN 3

 

 

 

 

Office Visits

Ded., then coinsurance

Ded., then coinsurance

$30 copay

 

 

 

 

Deductible

$250 ($500 family)

$500 ($1000 family)

$1000 ($2000 family)

 

 

 

 

Coinsurance

80%

80%

80%

 

 

 

 

Maximum Out of Pocket
(includes deductible)

$1250 ($2500 family)

$1500 ($3000 family)

$2000 ($4000 family)

 

 

 

 

Prescription Drugs

$1500 per calendar year out of pocket maximum

 

Retail - for 30 day supply:

Generic $0 + 20%

Listed Brand $15 + 20%

Non-Listed Brand $30 + 50%

 

 

 

Mail Order - for 90 day supply:

Generic $0 + 20%

Listed Brand $15 + 20%

Non-Listed Brand $30 + 50%

 

 

 

 

Supplemental Accident

$1500 per person per calendar year

 

 

 

 

Plan Maximum

$2,000,000 lifetime

 

 

 

 

In-Hospital

Deductible, then coinsurance

 

 

 

 

      Pre-Certification

Required for non-emergency, non-maternity admissions

 

 

 

 

      Pre-Certification       Penalty

$200 additional deductible

 

 

 

 

      Hospital Misc.

Deductible, then coinsurance

 

 

 

 

      Surgery

Deductible, then coinsurance

 

 

 

 

Wellness Benefit

 

$300 @ 100% per employee, spouse and all dependent children ages 7-25  annually
   

Well Child Care

Coverage is provided for the following physician-delivered or physician-supervised outpatient services at 100% R&C without regard to the deductible or coinsurance amounts for a covered dependent child

 

¨      Periodic examinations which include a history, physical examination, developmental assessment and anticipated guidance necessary to monitor the normal growth and development of the child.

 

¨      Oral and/or intramuscular injections for the purpose of immunizations.

 

¨      Laboratory tests.

 

The above services must conform with prevailing medical standards and will be available when the child attains the following ages:

 

1 month           12 months       36 months
2 months         15 months       48 months
4 months         18 months       60 months
6 months         24 months       72 months
9 months

 

 

Work Related Injuries

Covered to $200,000 per person annually per contract year

 

 

Manipulation of the Spine

$500 annual maximum

 

 

Rehabilitation Services

$100,000 lifetime maximum

 

 

Physical Therapy

40 visit maximum annually

 

 

Ambulances

$1000 maximum per ground trip

 

 

Bone Marrow Transplants / Peripheral Stem Cell Support

Autologous transplants limited to $150,000 per member per lifetime

 

 

Mental and Nervous

 

In Hospital

Deductible, then coinsurance
10 days per calendar year

Intensive Outpatient

Deductible, then coinsurance
½ day will be charged for each day toward inpatient 10-day max

Substance Abuse Inpatient

$7500 lifetime

 

 

Outpatient or Office Visits -
Mental/Nervous &
Substance Abuse

Deductible, then 50% coinsurance
25 days per calendar year

 

This comparison of coverages is intended only as a general description for the principle features of the benefit plans.  Please refer to the evidence of coverage for details.                                                                                                                  01/01/05

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