Classic Gold - $20 CoPay Individual| Physician Charges:-* | -- - |
| Routine Physical Exam or Immunizations | 100% after $20 CoPay per visit |
| Office or Hospital Visit | 100% after $20 CoPay per visit |
| Home Health Care Visit | 100% after $20 CoPay per visit |
| Pathology (Lab) Tests Radiology (X-ray) Tests |
100% after $10 CoPay per visit 100% after $50 CoPay per visit |
| Surgery or Anesthesiology Fee | 100% after $75 CoPay per visit |
| Mental Health Program (not covered out-of-network) |
100% after $75 CoPay per visit |
| Hospital and Other Facility Charges: * | --- |
| Inpatient Intensive Care (Includes pre-admission testing) |
100% after $300 CoPay per confinement |
| Outpatient Care (Includes facility, X-ray lab) |
100% after $300 CoPay per visit |
| Outpatient Mammogram | 100% after $50 CoPay per visit |
| Emergency Room (No CoPay if immediately confined) | 100% after $300 CoPay per visit |
| Mental Health Program (Not covered out-of-network) |
100% after $300 CoPay per confinement |
| Prescription Drug Benefit:* | --- |
| Prescription Drug Benefit | 100% after $15 CoPay |
| PPO Plan Maximums: * | --- |
| Combined PPO Non-PPO Lifetime Maximum | $2,500,000 |
| Deductible | None |
| Co-insurance (Non-Mental Health) | 100% |
| Out-of-Pocket Maximum (Mental Health & Prescription Drug benefits are not included) SINGLE: FAMILY: | $3,500 $7,000 |
| Mental Health Maximums INPATIENT: OUTPATIENT: | $3,000 per year $--750 per year |
| Mental Health Lifetime Maximum | $10,000 |
| Non-PPO Plan Maximums: * | --- |
| Deductible | $600 (Max. 3 per family) |
| Co-insurance Limits | 70% of $17,500 then 100% |
| Out-of-Pocket Maximum (Prescription Drug Benefits are not included) SINGLE: FAMILY: |
$ 5,850 $11,700 (Includes deductible) |
*Physician Charges: These are charges from the medical professionals you receive treatment form. Examples include physicians, physical therapists, home health care providers, and surgeons.
*Hospital & Other Facility Charges:These charges are from the actual facility where you receive treatment. Examples include hospitals, surgical centers, and emergency rooms.
*Prescription Drug Benefit: Present your Medical Security identification card to a participating pharmacy and the generic brand is covered after a CoPayment. If the generic brand is not available, a brand name drug will be dispensed for the same CoPay.
*Employee Assistance Program(EAP): The EAP offers confidential assessment, intervention, and referral services for educational concerns, addiction treatment, mental health needs, domestic issues, financial management, and legal concerns.
*Non-PPO Plan Maximums: (Covered non-PPO expenses are reimbursed to the Maximum Allowable Charge.)