Summary of Benefits In-Network Out-of-Network Sample Clauses

Summary of Benefits In-Network Out-of-Network. Hospital Services 90% after deductible 65% after deductible Physician Services Office Visits 90% after deductible 65% after deductible Surgery in office 90% after deductible 65% after deductible Surgery in hospital 90% after deductible 65% after deductible All Other Eligible Services 90% after deductible 65% after deductible Hospice Services Cover under MM 180-day lifetime max Chiropractic Services Limits 15 visits per calendar year Prescription Drug Benefit 90% after deductible* Preventative Care 100% Not Covered *Plan Deductible (Annual) Per Person $300 $600 In-Network Out-of-Network Per Family $500 $1100 Out-of-Pocket Limit * Per Person $800 $2100 Per Family $1300 $3100 *Includes Deductible Emergency Room Fee 100 $100 ● Occupational therapy is included as an eligible expense. ● Preventive diagnostic tests include a waiver of deductibles for routine pap test, mammography, and prostate exams paid at 100%, including the office visit. ● Home health care will be covered for 120 visits per year under major medical coverage. ● The definition of physician will include optometrists. ● Disability extension of benefits will be excluded. ● Deductible carryover benefits shall be eliminated. ● Two (2) members of the bargaining unit who are married to each other will be covered under one (1) family plan and will pay one (1) monthly family premium. ● An optional mail order prescription plan for maintenance drugs will be implemented. ● There will be non-duplication rules for coordinating benefits ● There will be no cross application of deductibles or out of pocket maximums in network or in non-network. *All eligible prescription drugs will be covered at the in-network coinsurance rate.