VIEWS: 23 PAGES: 3 POSTED ON: 2/13/2011
Prescription 15 (Generic) Card 35 (Brand) 60/OC/N/A/2x 90/day excl V (d Major Medical Deductible Member pays Ind/Fam $1000/$2000 Co-Insurance 80% Maximum $1500/$3000 Out-of-Pocket Office Co-pay $20 copay/No ded DXL/Lab Fees $30 copay/No ded Specialist Co-pay $30 copay/No ded Lifetime Maximum Unlimited Hospital Benefits Hospital In-Patient 80% after ded Hospital 80% after ded Out-Patient Emergency Room $50 copay/No ded Private Nursing Not Covered, except under HHC Surgical Benefits Surgical In-Patient Incl. Hosp Co-pay Surgical 80% after ded Out-Patient Mental Health Mental Nervous a) 80% after ded In-Patient 30d Cal Yr Substance Abuse a) 80% after ded In-Patient 30d/Cal Yr/90d/lifetime Mental Nervous a) $30 copay/No ded Out-Patient 20 visits/Cal Yr Substance Abuse a) $30 copay/No ded Out-Patient 20 visits/Cal Yr Other Well Care(Up to 19) $20 copay/No ded Routine Adult Care $20 copay/No ded Chiropractic Care $30 copay; 30 vistis/Cal Yr Home Health Care No copay; 60 visits per cal yr Non-Authorization Refer to Carrier Plan Information Single 232 EE with Spouse 486 EE with Child(ren) 410 Family 684 Medicare 0 Monthly Cost Annual Cost The rates and benefits in this report are for discussion and estimation purposes only and are not valid without approval from the insurance carriers. Final rates must be based on insurance carrier confirmation and final enrollment. (d) Non-Formulary / Oral Contraceptive / Deductible / Mail Order (Wellchoice includes Mail Order Generic, Brand, and Non-Formulary costs) (a) Biological based Mental Nervous & Alcohol Abuse/Treated same way as any other illness.
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