INPATIENT HOSPITAL Note. All hospital admissions require pre-cert General/Medical & Surgical 100% after deductible Ancillary Services (Medication, Supplies) 100% after deductible Psychiatric 100% after deductible Substance Abuse/Detox 100% after deductible Rehabilitative 100% after deductible Covered up to 100 days per calendar year. Add'l coverage after 100 days subject to OON deductible/coinsurance Skilled Nursing Facility 100% after deductible 120 days per calendar year Hospice 100% after deductible Outpatient Surgery 100% after deductible Facility Charges Diagnostic Lab & X-ray 100% after deductible Pre-Admission Testing 100% after deductible Durable Medical Equipment 100% after deductible Prosthetics 100% after deductible Home Health Care 100% after deductible 200 visits per calendar year. Infertility Services 100% after deductible Prescription Drugs After deductible is met: 2 x retail for mail order / $10 generic, $25 preferred brand, $40 non- preferred brand; Unlimited max. This insurance matrix appendix contains a summary and description of the HDHP Plan. It is agreed and understood by the parties that the insurance description contained in this matrix are descriptive only and is not the insurance policy. All questions or issues concerning insurance coverage and related matters shall be determined by reference to the actual insurance policy documents issued or possessed by the insurers and/or plan administrators. DENTAL INSURANCE Benefit $25 (applies to Basic Services and Major Services only) $75 (applies to Basic Services and Major Services only) $600 per member per lifetime for Category 3 All other categories are subject to a maximum of $2,000 per person per calendar year. Insured/spouse and unmarried dependents to age 25. For employees hired after July 1, 2004, dependents over 19 must also be full-time students Individual Deductible: Family Deductible: Lifetime maximum: Initial and periodic oral exams and cleanings Topical application of fluoride Payable at 100% of usual, customary and reasonable charges at participating dentists. Space maintainers X-rays Emergency Treatment Prophylaxis Space Maintainers
INPATIENT HOSPITAL Note. All hospital admissions require pre-cert COST SHARES
INPATIENT HOSPITAL Note. All hospital admissions require pre-cert General/Medical/ Surgical/Maternity (Semi-private) 100% Coinsurance after Deductible Ancillary Services Medication, supplies 100% Coinsurance after Deductible Psychiatric/ Alcohol Rehabilitation 100% Coinsurance after Deductible Substance Abuse/ Detox 100% Coinsurance after Deductible Rehabilitative 100% Coinsurance after Deductible Skilled Nursing Facility 100% Coinsurance after Deductible Covered up to 120 days per calendar year Hospice 100% Coinsurance after Deductible
More Definitions of INPATIENT HOSPITAL Note
INPATIENT HOSPITAL Note. All Hospital Note: All Hospital General/Medical/Surg./Maternity $500 co-pay Subject to the Deductible then Covered 100% (Semi-private) Limited to 3 copays annually Ancillary Services Covered Subject to the Deductible then Covered 100% (Medication, Supplies) Inpatient Psychiatric $500 co-pay Subject to the Deductible then Covered 100% Inpatient Substance Abuse/Detox $500 co-pay Subject to the Deductible then Covered 100% PPO PLAN PLAINFIELD HDHP Inpatient Rehabilitative Covered Subject to the Deductible then Covered 100% 180 combined days per calendar: Rehab, SNF and other Sub Acute Hospitals 180 combined days per calendar: Rehab, SNF and other Sub Acute Hospitals Skilled Nursing Facility Covered Subject to the Deductible then Covered 100% 180 combined days per calendar: Rehab, SNF and other Sub Acute Hospitals 180 combined days per calendar: Rehab, SNF and other Sub Acute Hospitals Hospice Covered Subject to the Deductible then Covered 100% Outpatient Hospital/Surg. Center Covered Subject to the Deductible then Covered 100% Outpatient Surgery Facility Charges Diagnostic Lab & X-ray Covered Subject to the Deductible then Covered 100% Pre-Admission Testing Covered Subject to the Deductible then Covered 100% Other Services Covered Subject to the Deductible then Covered 100% Durable Medical Equipment Prosthetics Covered Subject to the Deductible then Covered 100% Home Health Care Covered Subject to the Deductible then Covered 100% Prescription Drugs: $10 Generic/$20 (listed brand)/$30 (non- listed brand) mail order 1 times co-pay Unlimited annual maximum. Subject to the Deductible then co-pays: $0 Generic/$20 (listed brand)/$30 (non- listed brand) mail order 1 times co-pay Unlimited annual maximum. Managed Three Tier Page 3A
INPATIENT HOSPITAL Note. All hospital admissions require pre-cert General/Medical & Surgical 100% after deductible Ancillary Services (Medication, Supplies) 100% after deductible Psychiatric 100% after deductible Substance Abuse/Detox Covered 100% Rehabilitative 100% after deductible Covered up to 100 days per calendar year. Add'l coverage after 100 days subject to OON deductible/coinsurance Skilled Nursing Facility 100% after deductible 120 days per calendar year Hospice 100% after deductible Outpatient Surgery 100% after deductible Facility Charges Diagnostic Lab & X-ray 100% after deductible Pre-Admission Testing 100% after deductible