Platinum Group Plan $20/80% Copay

Physician Charges: *
Routine Physical Exam or Immunizations	80% after $20 Copay per visit
Office or Hospital Visit	80% after $20 Copay per visit
Home Health Care Visit	80% after $20 Copay per visit
Pathology (Lab) Tests Radiology (X-ray) Tests	80% after $20 Copay per visit 80% after $20 Copay per visit
Surgery or Anesthesiology Fee	80% after $75 Copay per visit
Mental Health Program (Not covered out-of-network)	Optional
Hospital and Other Facility Charges: *
Inpatient & Intensive Care (Includes preadmission testing)	80% after $350 Copay per confinement
Outpatient Care (Includes facility, X-ray & lab)	80% after $350 Copay per visit
Outpatient Mammogram	80% after $20 Copay per visit
Emergency Room (No copay if immediately confined)	80% after $350 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
Coinsurance (Non-Mental Health)	80%
Out-of-Pocket Maximum (Mental Health & Prescription Drug benefits are not  included)     Single:                                                     Family:	$3,500 $7,000 (Accumulated copays)
Non-PPO Plan Maximums: *
Deductible	$700 (Max. 2 per family)
Coinsurance Limits	50% of $10600- 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 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.

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.