| PPO PROVIDERS | OUT OF NETWORK | |
| Deductibles & Maximums | ||
|---|---|---|
| Deductible - Individual | $250 | $250 |
| Deductible - Family | $500 | $500 |
| Annual Out-of-Pocket | The out of pocket maximum is $1,500 per individual and $3,000 per family | The out of pocket maximum is $4,500 per individual and $9,000 per family |
| Maximum* | Deductible and office visits copayments do not apply to the out of pocket maximum. | Deductible and office visits copayments do not apply to the out of pocket maximum. |
| BENEFITS FOR COVERED SERVICES | ||
| Physician Services | ||
| Office visits | $15 COPAYMENT | $15 COPAYMENT |
| Hospital/Skilled Nursing visits | 80% | 60% |
| Specialists | $15 COPAYMENT | $15 COPAYMENT |
| Surgeon/Asst. Surgeon | 80% | 60% |
| Anesthesiologist | 80% | 60% |
| Diagnostic X-ray & Labs | 80% | 60% |
| Preventative Care | ||
| Early Detection | Available | Available |
| Well Baby Care | Covered from birth to age 3 | Covered from birth to age 3 |
| Immunizations | Covered from birth to age 3 | Covered from birth to age 3 |
| Hospital/Surgical Services | ||
| Inpatient | 80% | 60% |
| Outpatient | 80% | 60% |
| Emergency Services | ||
| Ambulance | 80% | 60% |
| Emergency Room | 80% after $50 copay, waived if admitted | 60% after $50 copay, waived if admitted |
| Maternity Services | ||
| Hospital Benefits - Delivery | 80% | 60% |
| Outpatient Physician Services | 80% | 60% |
| Surgical Services | 80% | 60% |
| Prescription Drugs | ||
| $100 Calendar Year Deductible, then | $100 Calendar Year Deductible, then | |
| Retail Purchase Limit of 2 fills per medication at a retail pharmacy, not to exceed 30 day supplies for each fill |
$10 Generic/$15 Preferred Brand/$30 Non-Preferred Brand |
$10 Generic/$15 Preferred Brand/$30 Non-Preferred Brand |
| Generic or Brand maximum amount | 30 day supply |
30 day supply |
| Mail Order Purchase Required for all maintenance medications, after 2 fills at a retail pharmacy, not to exceed 90 day supplies. |
$20 Generic and $30 Preferred Brand/$60 Non-Preferred Brand |
$20 Generic and $30 Preferred Brand/$60 Non-Preferred Brand |
| Generic or Brand maximum amount | 90 day supply |
90 day supply |
**IMPORTANT: The IBEW Local 617 drug plan requires utilization of the mail order pharmacy for medications taken on a long term basis. Copayments increase two fold upon the third prescription fill for any medication not filled by the plan's mail order pharmacy. Copayments are reduced by one third for ninety day supplies obtained through the mail order pharmacy. All new (first time) prescriptions for long term medications should first be filled at a local retail pharmacy for the first two fills, to evaluate efficacy and tolerability, before ninety day maintenance supplies are ordered through the mail order pharmacy. |
||
| other services | ||
| Chiropractic Services | 80%** | 60%** |
| Physical Therapy | 80%** | 60%** |
| Speech Therapy | 80%** | 60%** |
| Continued Care Services | ||
| Home Health Care | 80% | 60%** |
| Skilled Nursing Facility | Following discharge from an acute care facility, plan pays 90%. | Following discharge from an acute care facility, plan pays 60%. |