Overview of Benefits. This information will help you understand how this dental plan works and how to make it work best for you.
Overview of Benefits. Following is a brief overview of the proposed Xxxxxx Creek Health Care PPO Plan benefits. DEDUCTIBLE. COPAYMENTS AND DOLLAR MAXIMUMS IN-NETWORK OUT-OF-NETWORK Deductible None $250 individual, $500 family per calendar year Co-payment Dollar Maximums – excludes co-payments for private duty nursing. deductible, non-covered charges and charges in excess of plan benefits. None $2,000 individual, $4,000 family per calendar year Dollar Maximums $5,000,000 PREVENTIVE SERVICES Limit of up to $500 per family member annually _ Health Maintenance Exam 100% of approved amount Not covered one per calendar year Annual Gynecological Exam 100% of approved amount, one per calendar year. Not covered Pap Smear Screening 100% of approved amount, one per calendar year. Not covered Well-Baby and Child Care 100% of approved amount 6 visits per year through age 1 2 visits per year age 2 through 3 Not covered 1 visit per year age 4 through 15 Childhood Immunizations+ 100% of approved amount, through age 15. Not covered Fecal Occult Blood Screening 100% of approved amount, one per calendar year. Not covered Flexible Sigmoidoscopy Exam 100% of approved amount, Not covered one per calendar year. Prostate Specific Antigen (PSA) Screening+ 100% of approved amount, Not covered one per calendar year. Routine Lab and Radiology Services 100% of approved amount, Not covered associated with physical examination once per calendar year when performed as routine screening. • Chemical profile • Complete blood count or any of its components • Urinalysis • Chest x-ray • EKG +Age and frequency restrictions apply. PREVENTIVE SERVICES continued IN-NETWORK OUT-OF-NETWORK Routine Mammography* 100% of approved amount, one baseline between ages of 35-40. One per calendar year over age 40.+ 80% of approved amount after deductible, one baseline between ages of 35-40. One per calendar year over age 40.+ PHYSICIAN OFFICE SERVICES Office Visits $5. co-payment 80% of approved amount after deductible. Outpatient and Home Visits 100% of approved amount. 80% of approved amount after deductible. Office Consultations $5. co-payment 80% of approved amount after deductible. EMERGENCY MEDICAL CARE Hospital Emergency Room $25. co-payment, waived if admitted or for accidental $25. co-payment, waived if admitted or for accidental injury. injury. Physician’s Office $5. co-payment, waived if a medical emergency or accidental injury. 80% of approved amount after deductible, 100% of approved amount, no deductible if a medical...
Overview of Benefits. Alliance Options Select (AOS) is a modular annual health insurance plan for individuals, families and companies. There are four schemes with different levels of benefits. The benefits of the plan are designed to assist with the member’s access to, and use of, appropriate medical services for the maintenance of good health and for the treatment of disease, illness and injury. These benefits are detailed under the “What is Covered?” section of this booklet.
