• HOSPITAL

      Network Provider Non-Network Provider
    Calendar Year Deductible The Industry Health Network:
    $150/person; $300/family

    BlueCard PPO:
    $500/person; $1,000/family
    Not covered
    Inpatient (Room and Board and Ancillary Services) 90% Not covered*
    Outpatient Surgery 90% Not covered
    Emergency Room 90% after $200 copay;
    copay is waived if immediately confined
    Not covered*
    Coinsurance Out-of-Pocket Limit $1,750/person; $3,500/family Not covered
    *Emergency treatment within 72 hours after an accident or within 24 hours of a sudden and serious illness will be covered at the Network Level of Benefits.
     


  • MEDICAL

      Network Provider Non-Network Provider
    Calendar Year Deductible The Industry Health Network:
    None

    BlueCard PPO:
    $500/person; $1,000/family
    $750/person; $1,500/family
    Office Visit (including X-Ray and Lab) 90% after $25 copay 70% after $25 copay
    Surgeon - Inpatient 90% after $100 copay 70% after $100 copay
    - Outpatient Hospital, Surgical Center, Surgical Suite

    90% after $100 copay

    70% after $100 copay*
    Doctor's Office 90% after $25 copay 70% after $25 copay
    Maternity Care - Prenatal Visits No deductible; 100% 70%
    Delivery 90% after $100 copay 70% after $100 copay
    Routine Physical Exam No deductible; 100% Not covered
    Routine Child Exam No deductible; 100% Not covered
    Mammogram/Pap No deductible; 100% 70%
    Coinsurance Out-of-Pocket Limit $1,000/person; $2,000/family $2,500/person; $5,000/family
    Hospital/Medical Out-of-Pocket Maximum (includes Deductibles, Copays, Coinsurance) $6,850/person; $13,700/family None
    Other Benefits The following benefits are also available subject to specific rules:

    Therapy, Outpatient Nursing, Case Management.

    *If the surgery takes place in a non-network surgical suite or ambulatory surgical center, the Plan will allow up to $1,000 for use of the facility's operating and recovery rooms and all central supplies when medically necessary for the procedure performed. The Plan will also allow up to $1,000 for the use of a non-network birthing center. Coverage for network surgical suites and surgical centers and for network birthing centers is provided under the hospital benefits.

     


  • PRESCRIPTION DRUGS

    Participating Pharmacies Express Scripts Participating Retail Pharmacy Express Scripts Home Delivery (includes Specialty)
    Mental health/substance abuse medications are not covered. Specialty medications must be obtained by mail through the specialty pharmacy, Accredo.
    Calendar Year Deductible $150/person; $300/family
    Supply Up to a 30 day supply/prescription or refill Up to a 90 day supply/prescription or refill
    Copay The greater of: The greater of:
    Generic - $10 or 10% Generic - $20 or 10%;
    max copay is $50 / prescription
    Preferred Brand - $25 or 25% Preferred Brand - $50 or 25%;
    max copay is $125/prescription
    Non-Preferred Brand - $40 or 40% Non-Preferred Brand - $100 or 40%;
    max copay is $300/prescription

    In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

    Generic prescription contraceptives are covered at 100% with no deductible or copay.

    In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication subject to the maximum copays listed above.

    Generic prescription contraceptives are covered at 100% with no deductible or copay.

     
  • MENTAL HEALTH AND SUBSTANCE ABUSE

      Beacon Health Options (formerly ValueOptions) Provider Non-Network Provider
    Hospital and Alternative Levels of Care

    Not covered
    Medical
     
  • DENTAL

      Delta Dental PPO Provider Delta Premier and Non-Network Providers
      Must have three or more years of prior Earned Eligibility.
    Calendar Year Deductible $100/person; no family maximum;
    waived for diagnostic and preventive
    $100/person; no family maximum
    Diagnostic and Preventive Benefits 100% 60%
    Basic Benefits 60% 60%
    Major Benefits 50% 50%
    Calendar Year Maximum* $1,000 $1,000
    * There is no dental maximum for individuals under age 19.
     
  • VISION - EXAM PLUS PLAN

      Vision Service Plan Provider Non-Network Provider
    Eye Exams

    Not covered
    Glasses
    Professional Services for Contact Lenses