Page 11 - CPS Benefits Guide
P. 11
Montana, Oregon, and
Vermont Only
PPO Plan HSA Plan Out-of-Area Plan
In-Network Out-of-Network In-Network Out-of-Network In/Out-of-Network
Mental Health/Substance Abuse
Inpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Outpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Skilled Nursing Care 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Home Healthcare 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Hospice Care 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Durable Medical 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Equipment
Chiropractic Care $40 copay 50% after ded . 70% after ded . 50% after ded . $40 copay PCP/$60
PCP/$60 copay copay specialist
specialist
Limitations Preventive Limited to 30 Limited to 30 Limited to 30 visits per
Drugs Covered at 100% visits per year visits per year year
Outpatient Therapies—Limited to 30 visits per year
Physical Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Speech Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Occupational Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Prescription Drugs*
Retail—Supply Limit 31 Days
Tier 1 $15 copay $15 copay 70% after ded . 70% after ded $15 copay
Tier 2 $50 copay $50 copay 70% after ded . 70% after ded $50 copay
Tier 3 $100 copay $100 copay 70% after ded . 70% after ded $100 copay
Mail Order—Supply Limit 90 Days
Tier 1 $30 copay N/A 70% after ded . N/A $30 copay
Tier 2 $100 copay N/A 70% after ded . N/A $100 copay
Tier 3 $200 copay N/A 70% after ded . N/A $200 copay
* Preventive drugs covered at
100% in the HSA plan
Please refer to the plan’s Summary Plan Descriptions for further detail located on the ADP portal.
Comprehensive Pharmacy Services 11
Vermont Only
PPO Plan HSA Plan Out-of-Area Plan
In-Network Out-of-Network In-Network Out-of-Network In/Out-of-Network
Mental Health/Substance Abuse
Inpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Outpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Skilled Nursing Care 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Home Healthcare 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Hospice Care 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Durable Medical 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Equipment
Chiropractic Care $40 copay 50% after ded . 70% after ded . 50% after ded . $40 copay PCP/$60
PCP/$60 copay copay specialist
specialist
Limitations Preventive Limited to 30 Limited to 30 Limited to 30 visits per
Drugs Covered at 100% visits per year visits per year year
Outpatient Therapies—Limited to 30 visits per year
Physical Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Speech Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Occupational Therapy 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Prescription Drugs*
Retail—Supply Limit 31 Days
Tier 1 $15 copay $15 copay 70% after ded . 70% after ded $15 copay
Tier 2 $50 copay $50 copay 70% after ded . 70% after ded $50 copay
Tier 3 $100 copay $100 copay 70% after ded . 70% after ded $100 copay
Mail Order—Supply Limit 90 Days
Tier 1 $30 copay N/A 70% after ded . N/A $30 copay
Tier 2 $100 copay N/A 70% after ded . N/A $100 copay
Tier 3 $200 copay N/A 70% after ded . N/A $200 copay
* Preventive drugs covered at
100% in the HSA plan
Please refer to the plan’s Summary Plan Descriptions for further detail located on the ADP portal.
Comprehensive Pharmacy Services 11
