Page 6 - RSD Guide

Select Med Plus and Select Care Plus Benefits

Participating Non-Participating
In-Network Out-of-Network
When using participating When using non-participating
providers, you are responsible to providers, you are responsible to
pay the amounts in this column pay the amounts in this column
Conditions and Limitations
Lifetime maximum plan payment None None
Pre-existing conditions (PEC) and limitations None None
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 $500/$1,000 $750/$1,500
Out-of-pocket maximum
This amount is your deductible + your maximum $3,000/$6,000 $4,000/$8,000
coinsurance and copay
Inpatient Services
Medical, surgical, hospice, emergency admissions
Skilled nursing facility
Up to 60 days/calendar year 20% after deductible 40% after deductible
Rehab therapy: physical, speech, occupational
Up to 40 days/calendar year for all therapy types
combined
Professional Services
Ofice visits and ofice surgeries
Primary Care Provider (PCP) $35 40% after deductible
($35 minimum copay)

Secondary Care Provider (SCP) $50 40% after deductible
($50 minimum copay)
Allergy tests See ofice visits Not covered
Allergy treatment and serum 20% Not covered
Physician’s fees—medical, surgical, anesthesia 20% after deductible 40% after deductible
Preventive Services as Outlined by the ACA
Ofice visits (PCP/SCP)
Adult and pediatric immunizations Covered 100% Not covered
Diagnostic tests: minor
Other preventive services

6

2015 Benefit Guide