| |
Beneficial Value (PPO)
|
| Lifetime benefit maximum |
$2,000,000
($250,000 can be accessed out of network)
|
Plan year deductible, individual
(family is 3x the individual) |
$1,000 / $2,500 / $5,000 / $7,500
|
Out-of-pocket maximum, per
person
(after deductible) |
$5,000
|
$10,000
|
| Preventive Care |
Member Responsibility
|
| |
In-Network
|
Out-of-Network
|
| Annual women's exam, pap test, pelvic
and breast exam |
$25 co-pay*
|
50%
|
| Women's routine mammogram |
$25 co-pay*
|
50%
|
| Well-baby care, primary care physician
(PCP) |
$25 co-pay*
|
Not covered |
| Routine physical exams |
$25 co-pay*
|
Not covered
|
| Immunizations |
$0*
|
Not covered
|
| Professional Services |
| Office visits |
First 3 at $25**
|
50%
|
Alternative care ($1,000 per plan year
limit)
Chiropractic, naturopathic and acupuncture |
First 3 at $25**
|
50% |
| Maternity |
All pre/post office visits and doctor
delivery; hospital charges
(12 month exclusion period) |
30%
|
50%
|
| Hospital Services |
| Inpatient and outpatient surgery; room,
ancillary and physician charges; skilled nursing facility care |
30%
|
50%
|
Emergency Services
(deductible applies) |
| Urgent Care |
$25** co-pay
|
50%
|
| Hospital emergency room |
30% after $100 copayment
|
| Ambulance |
30%
|
| Other Facilities and Services |
| Lab and X-ray services, rehabilitation
services, medical supplies and devices; in-hospital care; home healthcare |
30%
|
50%
|
| Prescription services |
***Optional $15 generic or 50% , $2,000 max; deductible waived.
|
| Accident benefit |
Deductible waived for treatment
completed within 90 days |
|
*The plan deductible is waived for these
services.
**The Beneficial plans pay the first three office visits
with a $25 co-payment, which may be used for either illness and injury visits
or the preventive care exam. Alternative care includes an additional
three visits with a $25 co-payment. Thereafter, the deductible and co-insurance
applies to the benefit maximum.
***Can purchase prescription rider separately; benefit is $15 generic or 50% brand, $2,000 maximum benefit; deductible waived.
Fixed dollar copayments, out-of-pocket expenses for prescription drugs and
disallowed charges do not apply to the annual deductible or to the out-of-pocket
maximum. Expenses applied toward the annual deductible do not aply to the
out-of-pocket maximum. Expenses for transplants performed at non-participating
transplant facilities and service authorization cost containment penalty
do not apply to the out-of-pocket maximum.
|
Plan Updates 
