Page 7 - Hussmann- OE Guide

Hussmann Corporation

2015 Medical Benefits
PPO CHP
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $750 Each Person $1,500 Each Person $1,500 Individual (See Below)
$1,500 Family $3,000 Family $3,000 Family (See Below)
Prescription drugs not subject to deductible Prescription drugs subject to deductible
Annual Out-of-Pocket $2,750 Each Person $5,500 Each Person $2,975 Individual $5,950 Individual
Maximum $5,500 Family $11,000 Family $5,950 Family $11,900 Family
Includes deductibles; prescription drugs do not Includes deductibles; prescription drugs count
count toward medical maximum toward medical maximum
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Preventive Care (For example: routine physicals, x-rays and lab tests, immunizations, routine mammogram and gynecological exam,
sigmoidoscopy, vision, and hearing screenings)
100% No deductible 60% No deductible 100% No deductible 60% No deductible
Physician Services/Outpatient Care
Physician Ofice Visit 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient Surgery (performed 80% after deductible 60% after deductible 80% after deductible 60% after deductible
in physician ofice, hospital, or
freestanding facility)
Diagnostic Tests 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Chiropractic Care 80% after deductible 80% after deductible 80% after deductible 80% after deductible
Emergency Medical Care
Emergency Room ($75 penalty 80% after deductible Covered at 80% after deductible Covered at
for non-emergency use) in-network level in-network level
X-Rays and Lab Tests 80% after deductible Covered at 80% after deductible Covered at
in-network level In-network level
Ambulance Services 80% after deductible Covered at 80% after deductible Covered at
in-network level in-network level
Inpatient Hospital Care
Physician/Surgical Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Semi-Private Room and Board 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Maternity Care 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Mental Health and Substance Abuse
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Additional Services
Physical, Occupational, and 80% after deductible 80% after deductible 80% after deductible 80% after deductible
Speech
Home Health Care, Extended 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Care Facility
Hospice; private duty nursing; 80% after deductible 80% after deductible 80% after deductible 80% after deductible
durable medical equipment;
prosthetic devices

Important Deductible and Out-of-Pocket Maximum Notice for CHP Plan Participants

The Individual Deductible does not apply to Employees’ with dependent coverage in the CHP plan. For example, if you incurred
$2,000 in medical expenses, the plan will not pay until you, or other members of your family, have accumulated medical
expenses in excess of $3,000. This applies to out-of-pocket maximums as well.

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