Page 6 - Guide

Select Med Plus and Select Care Plus Benefits

Participating Non-Participating

In-Network Out-of-Network
When using non-
When using participating participating providers,
providers, you are you are responsible to
responsible to pay the pay the amounts in this
amounts in this column column

Conditions and Limitations
Lifetime Maximum Plan Payment None None
Pre-Existing Conditions (PEC) and None None
Limitations
Maximum Annual Out-of-Network Payment None $2,000,000
(per calendar year)
Medical Deductible and Medical Out-of-
Pocket Individual/Family Individual/Family
Calendar year deductible and out-of-pocket maximum; deductible is included in the out-of-pocket
maximum
Deductible $1,000/$2,500 $1,500/$3,000
Out-of-Pocket Maximum $4,000/$8,000 $6,000/$12,000
This amount is your deductible + your
maximum coinsurance and copay
Inpatient Services
Medical, Surgical, Hospice, Emergency 20% after deductible 50% after deductible
Admissions
Skilled Nursing Facility
Up to 60 days/calendar year
Rehab Therapy: Physical, Speech,
Occupational
Up to 40 days/calendar year for all
therapy types combined
Professional Services
Office Visits and Office Surgeries
Primary Care Provider (PCP) $25 50% after deductible
($25 minimum copay)
Secondary Care Provider (SCP) $40 50% after deductible
($40 minimum copay)
Allergy Tests See office visits Not covered
Allergy Treatment and Serum 20% Not covered
Physician’s Fees—Medical, Surgical, 20% after deductible 50% after deductible
Anesthesia
Child Dental and Vision Care
Eye Exam $40 per visit 50% coinsurance
Glasses 20% coinsurance 50% coinsurance
Dental Check-up $40 per visit Not covered

6 RallySport Direct