Pre 65 Retiree Plan
Effective January 1, 2014
Calendar Year Deductible
Individual
Family
Out-of-Pocket Maximum1
Individual
Family
Coinsurance
Covered Services
Emergency/Urgent Care Services
Emergency Room Visit
Emergency Room Physicians
Urgent Care Services
Hospital Facility Only
Inpatient Services
Outpatient Services
Surgical Services
Outpatient Surgery Center
Office Surgery
Surgeon Services
Anesthesia Services
Reproductive Care
Pre and Postpartum Maternity
Care Visits
Childbirth Education classes
1
In-Network
Out-of-Network
$200
$400
$400
$800
$1,500
$3,000
90%
$3,000
$6,000
70%
In-Network
Out-of-Network
$75 Co-payment per visit
(Co-payment waived if admitted)
90% of R&C subject to
90% subject to deductible
deductible
70% of R&C subject to
$35 Co-payment per visit
deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
to
to
to
to
$20 Co-payment
initial visit only
70% of R&C subject to
deductible
Not Covered
Not Covered
Excludes Prescription Co-payments and Coinsurance, Prior Authorization
Penalties and amounts over Reasonable and Customary Charges.
Pre 65 Retiree Plan
Effective January 1, 2014
Covered Services
Elective Sterilization
Infertility Diagnosis and Medical
Treatment
Fertility Treatments
In-Network
See the surgical services
benefit
90% subject to deductible
(office visit co-payment will
apply if applicable)
Out-of-Network
See the surgical services
benefit
Not Covered
Not Covered
Mental Health and Substance Abuse/Alcohol Abuse Services
Inpatient
90% subject to deductible
Outpatient
Detoxification
Residential
Preventive Care Services
Adult Routine Well Care Visit
Child Routine Well Care Visit
Other Well Care Services
(As defined by Health Care
Reform)
Medical Services
Allergy Tests
Desensitization Treatment
Specialist Office Visits
Primary Physician Office Visits
Services performed during a
physician’s office visit
Convenience Clinics
Inpatient Physician Services
Outpatient Physician Services
$20 Co-payment per visit
90% subject to deductible
Not Covered
100%
100%
100%
90% subject to deductible
100%
$25 Co-payment per visit
$20 Co-payment per visit
90% subject to deductible
$20 Co-payment per visit
90% subject to deductible
90% subject to deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
Not Covered
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
70% of R&C subject
deductible
to
to
to
to
to
to
to
to
Pre 65 Retiree Plan
Effective January 1, 2014
Covered Services
Other Services
Ambulance Services
Non Emergent Transport
Diabetic Supplies
(Monitors when provided in
conjunction with supplies,
Lancets, Test Strips and Control
Solutions)
Durable Medical Equipment
Habilitative Care Services
(limited to 20 visits each per
year for speech and occupational
therapy; 20 hours per week for
clinical therapeutic intervention;
and 30 visits per year for
mental/behavioral health)
Home Health Care
(limited to 120 days)
Hospice Care
Rehabilitative/Therapy Services
(limited to 60 visits per year;
includes physical, occupational,
speech, cardiac, chiropractic and
acupuncture)
Skilled Care Facility
(limited to 120 days)
Diagnostic X-ray & Laboratory
Services
TMJ
(limited to $3,000 per lifetime
for non surgical treatment)
Transplants
All Other Covered Services
In-Network
90% subject to deductible
90% subject to deductible
Out-of-Network
70% of R&C subject to
deductible
70% of R&C subject to
deductible
100%
70% of R&C subject to
deductible
90% subject to deductible
70% of R&C subject to
deductible
90% subject to deductible;
$20 copay/visit for
mental/behavioral health
services
70% of R&C subject to
deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
90% subject to deductible
(office visit co-payment will
apply if applicable)
90% subject to deductible
90% subject to deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible
70% of R&C subject to
deductible