Page 6 - ProModel 2015 Benefits Guide
P. 6
Medical Plan Summary
Our health insurance program is administered by Capital BlueCross. Highlights of the plan are below.
Beneit In-Network Non-Network
Calendar year deductible—individual/family None $200/$400
Calendar year coinsurance—individual/family None $800/$1600
Inpatient hospital—facility and physician 100% 80% after deductible
Outpatient—facility and physician including ofice surgery 100% 80% after deductible
Outpatient emergency room treatment—facility and treatment $50 copay, then 100% $50 copay, then 100%
Skilled nursing facility/doctor visits—max 120 days per cal year 100% 80% after deductible
Hospice 100% 80% after deductible
Physician ofice visits including in ofice services $10 copay, then 100% 80% after deductible
Preventive care
Well child exam $10 copay, then 100% Not covered
Age 0 to 1 year 4 visits
1 to 3 years 2 visits
3 to 20 years 1 visit every 24 months
Related diagnostic tests & x-rays 100% Not covered
Immunizations 100% 80% after deductible
Adult physical exam—1 every 12 months $10 copay, then 100% Not covered
Related diagnostic tests and x-rays 100% Not covered
Immunizations including lu shots, lyme disease and meningitis, 100% 80% after deductible
gardisil vaccine—females between 9 -26 of age
Gynecological examination $10 copay, then 100% 80% after deductible
Pap smear 100% 80% after deductible—limited
to 1 per calendar year
Mammogram—1 per calendar year 100% 80% after deductible
Prostate speciic antigen test 100% 80% after deductible
Diagnostic lab and x-ray 100% 80% after deductible
Chiropractic services—30 visits or $1,500 calendar yr maximum $10 copay, then 100% 80% after deductible
Outpatient therapy services; physical, speech, occupational, 100% 80% after deductible
cardiac, respiratory, radiation, chemotherapy, etc.
Infertility—$1,500 maximum per calendar year and $5,000
lifetime 100% 80% after deductible
Home healthcare 100% 80% after deductible
Durable medical equipment 100% 80% after deductible
Ambulance (limited to transport during a medical emergency) 100% 100%
Ambulance (non-emergency precertiication required) 100% 80%
Dialysis 100% 80% after deductible
All other covered services 100% 80% after deductible
Mental illness and substance abuse treatment—outpatient,
inpatient, partial hospitalization 100% 80% after deductible
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Our health insurance program is administered by Capital BlueCross. Highlights of the plan are below.
Beneit In-Network Non-Network
Calendar year deductible—individual/family None $200/$400
Calendar year coinsurance—individual/family None $800/$1600
Inpatient hospital—facility and physician 100% 80% after deductible
Outpatient—facility and physician including ofice surgery 100% 80% after deductible
Outpatient emergency room treatment—facility and treatment $50 copay, then 100% $50 copay, then 100%
Skilled nursing facility/doctor visits—max 120 days per cal year 100% 80% after deductible
Hospice 100% 80% after deductible
Physician ofice visits including in ofice services $10 copay, then 100% 80% after deductible
Preventive care
Well child exam $10 copay, then 100% Not covered
Age 0 to 1 year 4 visits
1 to 3 years 2 visits
3 to 20 years 1 visit every 24 months
Related diagnostic tests & x-rays 100% Not covered
Immunizations 100% 80% after deductible
Adult physical exam—1 every 12 months $10 copay, then 100% Not covered
Related diagnostic tests and x-rays 100% Not covered
Immunizations including lu shots, lyme disease and meningitis, 100% 80% after deductible
gardisil vaccine—females between 9 -26 of age
Gynecological examination $10 copay, then 100% 80% after deductible
Pap smear 100% 80% after deductible—limited
to 1 per calendar year
Mammogram—1 per calendar year 100% 80% after deductible
Prostate speciic antigen test 100% 80% after deductible
Diagnostic lab and x-ray 100% 80% after deductible
Chiropractic services—30 visits or $1,500 calendar yr maximum $10 copay, then 100% 80% after deductible
Outpatient therapy services; physical, speech, occupational, 100% 80% after deductible
cardiac, respiratory, radiation, chemotherapy, etc.
Infertility—$1,500 maximum per calendar year and $5,000
lifetime 100% 80% after deductible
Home healthcare 100% 80% after deductible
Durable medical equipment 100% 80% after deductible
Ambulance (limited to transport during a medical emergency) 100% 100%
Ambulance (non-emergency precertiication required) 100% 80%
Dialysis 100% 80% after deductible
All other covered services 100% 80% after deductible
Mental illness and substance abuse treatment—outpatient,
inpatient, partial hospitalization 100% 80% after deductible
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