Platinum Group Plan| Physician Charges:* |  -- -- |
| Routine Physical Exam or Immunizations | 100% after $15 CoPay per visit |
| Office or Hospital Visit | 100% after $15 CoPay per visit |
| Home Health Care Visit | 100% after $15 CoPay per visit |
| Pathology (Lab) Tests Radiology (X-ray) Tests |
100% after $15 CoPay per visit 100% after $15 Copay per visit |
| Surgery or Anesthesiology Fee | 100% after $50 CoPay per visit |
| Mental Health Program (Not covered out-of-network) | Optional |
| Hospital and Other Facility Charges:* | ---- |
| Inpatient & Intensive Care (Includes pre-admission testing) | 100% after $250 CoPay per confinement |
| Outpatient Care (Includes facility, X-ray & lab) | 100% after $250 CoPay per visit |
| Outpatient Mammogram | 100% after $15 CoPay per visit |
| Emergency Room (No CoPay if immediately confined) | 100% after $250 CoPay per visit |
| 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: |
$2,000 $4,000 (Accumulated CoPays) |
| Non-PPO Plan Maximums:* | ---- |
| Deductible | $500 (Max. 3 per family) |
| Co-insurance Limits | 50% of $11,000 then 100% |
| Out-of-Pocket Maximum (Prescription Drug benefits are not included) Single: Family: |
$ 6,000 $12,000 (Includes deductible) |
*
Physician Charges: These are charges from the medical professionals you receive treatment from. 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.
EAP - three assessment visits per plan year for the insured and each dependant as needed and determined by the EAP.
Non-PPO Plan Maximums: (Covered non-PPO expenses are reimbursed to the Maximum Allowable Charge.)
This is an outline of benefits used for the sole purpose of educating agents and is not to be used for sales presentations to prospective clients. Contact your regional or district sales office for additional information and marketing supplies.