Page 10 - Touching All the Bases- Power point 2023 v2_Neat
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Medical Plan Benefits Summary - continued
In-Network Out-of-Network
Durable Medical Equipment, Orthotics,
Prosthetics 100% 80% after deductible
Skilled Nursing Facility Care 100% 80% after deductible
Combined Limit: 100 days per calendar year
Home Health Care 100% 80% after deductible
Allergy Injections 100% 80% after deductible
Private Duty Nursing 100%
Hospice 100% 80% after deductible
Inpatient Mental Health 100% 80% after deductible
Outpatient Mental Health 100% 80% after deductible
Inpatient Substance Abuse
Detoxification 100% 80% after deductible
Rehabilitation 100% 80% after deductible
Outpatient Substance Abuse $15 copay 80% after deductible
Precertification is your responsibility; $1,000 penalty
Precertification Requirements
may apply if you don’t pre-certify your care
Premier Prescription Drug Program Retail Drugs (30-day supply)
(Defined by Premier Gold Pharmacy $10 copay / $20 copay / $35 copay
Network; Not by physician network)
(Generic / Brand-Formulary / Brand Formulary Maintenance Drugs through Mail Order (90-day supply)
Mandatory Generic) $20 copay / $40 copay / $70 copay
Click here for a detailed Medical Plan Summary
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