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| Descriptionof Benefits |
$20Copay Plan
$10,000 Deduct. |
$35Copay Plan
$7,500 Deductible |
$35Copay Plan
$10,000 Deductible |
| OfficeVisits - (PPOPhysicians and Specialists-includes X-ray and lab work onlywhen performed and billed by the physician's office) |
$20/$55 |
$30/$50 |
$30/$50 |
| LifetimeMaximum Per Member |
$6,000,000 |
$6,000,000 |
$6,000,000 |
AnnualDeductible Per Member
(3person maximum) |
$10,000 |
$7,500 |
$10,000 |
AnnualOut-of-Pocket Maximum
(3person family maximum) |
$2,500plus deductible per member |
$5,000plus deductible per member |
$10,000plus deductible per member |
| OfficeVisits - (PPOPhysicians and Specialists-includes X-ray and lab work onlywhen performed and billed by the physician's office) |
$20/$55 |
$30/$50 |
$30/$50 |
| PreventiveCare for Babies and Children (throughage 5) |
$20 |
$35 |
$35 |
PreventiveScreenings for Adults
(unlimited yearly max)
Colonscopywill be paid at 70% after the yearly deductible is met. |
$20 |
$35 |
$35 |
Mammograms
Preventive
and
Diagnostic |
Coveredat 100% - no copay |
Coveredat 100% - no copay | Coveredat 100% - no copay |
ProfessionalServices
Including surgery, anesthesia, in-hospital physician care, diagnosticX-ray and lab. |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
InpatientHospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
| Maternity |
NOTCOVERED |
NOTCOVERED |
NOTCOVERED |
| OutpatientMedical Care |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
ShortTerm Therapies:
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
(nolimit on # of visits)
Developmental Delay is not covered |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
Chiropractic Services
(24 visits per year - Care must be received from ActivHealthProvider) |
$10 |
$10 |
$10 |
Mental Health
Available only by purchase of an additional rider(rider gives 48 O/P Vis & 30 I/P days per yr.) |
Available only by purchasing a Rider | Available only by purchasing a Rider | Available only by purchasing a Rider |
| InfusionTherapy/Chemotherapy |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
EmergencyRoom Care -
ForMedical Emergency or Serious Accidental Injury
(Non emergency use of the emergency
room is not a covered benefit) |
$150 copay then 100% coverage |
$500 copay then 100% coverage |
$500 copay then 100% coverage |
| UrgentCare |
$55Copay |
$75Copay |
$75Copay |
| AmbulatorySurgical Center |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
| AmbulanceService |
$150 |
70% |
70% |
| Hospice |
Planpays 70% with deductible waived |
Planpays 70% with deductible waived |
Planpays 70% with deductible waived |
Home HealthCare -
Limited to 30 days, in and out of network combined |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
DurableMedical Equipment, Prosthetics and Orthoses
limitedto $2,500 annual max, all combined |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
SkilledNursing Facility
Limited to 30 days, in and out of network combined |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
Transplants
(Unlimited Benefit) |
Planpays 70% after deductible |
Planpays 70% after deductible |
Planpays 70% after deductible |
Prescription Drugs -
Retail Drugs - per prescription (up to a 30-day supply-mail orderavailable) |
After a $500 deductible per person, you pay: |
After a $2,000 deductible per person, you pay: |
After a $2,000 deductible per person, you pay: |
Tier 1(Generic Drugs)
(Available Without Meeting any Deductible) | $10copayment |
$10copayment |
$10copayment |
| Tier 2(Formulary Brand) | $35copayment |
$35copayment |
$35copayment |
| Tier 3(Non-Formulary Brand) | $50copayment |
$50copayment |
$50copayment |
| Tier 4(self edministered injectables) | $100copayment |
$100copayment |
$100copayment |
| Dental ( all care must be received from a DeltaCare HMOprovider) |
VariousCopays |
VariousCopays |
VariousCopays |
| Vision - one exam every 12 months (care must bereceived from an Avesis provider |
$15Copay |
$15Copay |
$15Copay |
| Descriptionof Benefits |
$20Copay Plan
$10,000 Deduct. |
$35Copay Plan
$7,500 Deductible |
$35Copay Plan
$10,000 Deductible |
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