Benefits |
Premier Plan |
CMPP/HSA Plan |
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test |
PPO |
NON-PPO |
PPO |
NON-PPO |
Deductibles Per Year |
Individual $750 Family $1,500 |
$2,700.00 |
No coverage provided |
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$5,450.00 |
No coverage provided |
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Out-of-Pocket Maximum Per Year |
Individual $750 Family $1,500 |
Unlimited Unlimited |
Not Applicable |
No coverage provided |
Not Applicable |
No coverage provided |
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Plan Co-Payment Rate |
75% after deductible | 60% after deductible | 100% after deductible | No coverage provided |
Primary Care Physician Co-Pay |
100% after $25 Individual Co-Payment per office visit to $300, other PPO Primary Care Physician Services 75% after deductible. | 60% after deductible | 100% after deductible | No coverage provided |
Specialist Physician Co-Pay |
100% after $60 Individual Co-Payment per office visit to $300, other PPO Specialist Physician Services 75% after deductible. | 60% after deductible | 100% after deductible |
No coverage provided |
Wellness Benefit, Includes routine pre-natal and well-child care, child and adult immunizations, mammograms, pap smears |
Not Applicable |
Not Applicable |
PPO Provider - 100 % No Deductible/ $2000 cap per member. Can use Limited Purpose FSA for reimbursement if needed |
No coverage provided |
Emergency Room Deductible |
$250 (waived if admitted or if life threatening) |
100% after deductible |
No coverage provided |
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Outpatient Surgery |
75% after deductible | 60% after deductible | 100% after deductible |
No coverage provided |
Prescription Drug Co-Payments |
Retail (30 Day Supply) Generic - $10; Preferred Brand - $40; Non-Preferred Brand - $50 or 50% of retail cost (whichever is greater); Mail order - (90 Day Supply) Generic - $30; Preferred Brand - $120; Non-Preferred Brand - $150 or 50% of retail cost (whichever is greater) | Subject to Deductible Will pay discount rae - not retail rate 100% after deductible Must use HSA for Reimbursement |
No coverage provided |
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Chiropractic Care |
50% after deductible to $500 annual maximum ($40 per visit allowed) |
No coverage provided Limited Purpose FSA |
No coverage provided |
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Mental/Nervous Benefit |
Inpatient - maximum 30 days per year @ 50% after deductible Outpatient - maximum 20 visits per year @ 75% after deductible |
Inpatient - maximum 30 days per year @ 100% after deductible Outpatient - maximum 20 visits per year @ 100% after deductible |
No coverage provided |
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Drug & Alcohol Abuse |
Individual Lifetime Maximum - $16,000 Maximum Benefit Per Year - $8,000 Plan Co-Payment Rate - 75% after deductible |
Individual Lifetime Maximum - $16,000 Maximum Benefit Per Year - $8,000 Plan Co-Payment Rate -100% after deductible |
No coverage provided |
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No coverage provided |
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No coverage provided |
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Routine Physicals (All Covered Persons) |
PPO Provider - 100 %, no deductible | No coverage provided |
Covered Under Wellness Benefit |
No coverage provided |
Routine Pediatric Care (includes immunizations) |
Covered to age 6, under physician office visit co-pay | Covered to age 6, after deductible | Covered Under Wellness Benefit |
No coverage provided |
Adult Immunizations |
Covered | Covered | Covered Under Wellness Benefit |
No coverage provided |
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[Updated 12/29/2005]