Agenda - 10-02-1995 - IX-C - Laserfiche WebLink

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11 • BENEFITS PLAN S3 ATTACHMENT 2 SERVICES PREFERRED BENEFITS NONPREFERRED BENEFITS Deductible $200 per calendar year $300 per calendar year (maximum of$600 per family) (maximum of$900 per family) Out-of-Pocket Limit - ---------------- . - $1,000 per member 52,000 per member $2,000 per family $4,000 per family Lifetime Maximum $1,000,000 per member Chemical Dependency Maximums' Calendar year $8,000 per member Lifetime $16,000 per member Physician Services Office visits 90% covered 80% PRC' Inpatient care 90% covered 80% PRC Surgery 90% covered 80% PRC Outpatient diagnostic 90% covered 80% PRC Maternity care 90% covered 80% PRC Chemical dependency' 90% covered 80% PRC Ambulatory Surgical Facility Services 90% covered 80% PRC' Hospital Services Per confinement deductible None None Inpatient 90% covered 80% PRC Outpatient 90% covered 80% PRC Chemical dependency' 90% covered 80% PRC Facility Provider Services Durable medical equipment 90% covered 80% PRC Private duty nursing care' 90% covered 80% PRC Home health care 90% covered 80% PRC Hospice care 90% covered 80% PRC Chemical dependency treatment facility' 90% covered 80% PRC Psychiatric Services Per confinement deductible None None Inpatient 90% covered 80% PRC Outpatient 70% covered 50% PRC Calendar year maximum $6,000 per member Lifetime psychiatric maximum $25,000 per member Emergency Care' Hospital services 90% covered 90% PRC(initial visit)* Physician services 90% covered 90% PRC(initial visit)' The following services are subject to the preferred benefits deductible of$200. Special Services/Providers' Ambulance services 80% PRC 80% PRC Prescription drugs 80% PRC 80% PRC Prosthetic appliances 80% PRC 80% PRC Orthotic devices 80% PRC 80% PRC Dental services related to injury 80% PRC 80% PRC Skilled nursing facility 80% PRC 80% PRC 'See reverse for explanation.