Page 11 - My FlipBook
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Americare
Essential Med Plan
Beneits
Preventive Care
Preventive beneits are covered at 100%; visit www.healthcare.gov for a complete list of beneits Covered at %100
no copay
Hospital Coninement
Day 1 beneit amount $750 per day x 1 day per year
Days 2+ beneit amount per day $500 thereafter
Maximum beneit 5 days per year
Additional surgical beneit $500 per day x 1 day per year
Additional anesthesia beneit $125 per day x 1 day per year
Outpatient
Physician ofice visit prepay $10
Beneit amount per visit $85 per day x 3 days per year
Accident maximum beneit amount per year Up to $1,000 per year, 80%
payable U&C, $0 deductible
Emergency room (sickness) beneit amount per visit $250 per day x 2 days per year
Surgery beneit amount per surgery $500 per day x 1 day per year
Anesthesia beneit amount per surgery $125 per day x 1 day per year
Diagnostic, x-ray, lab-beneit amount per test
Class I: laboratory—blood work, CMP, lipid panel $30 x 4 test days per year
Class II: x-ray, ECG, PAP/PSA tests, all other diagnostic $75 x 2 test days per year
Class III: ultrasound, mammogram $125 x 1 test day per year
Class IV: CT, PET, MRI $250 x 1 test day per year
Prescription
Retail—generic Rx copay (retail/mail order) $10/$30
Retail—preferred brand Rx copay (retail/mail order) Discount only
Monthly beneit maximum—individual/family $200/$400
AD&D
Accidental death and dismemberment beneit amount (employee/spouse/each child) $15,000/5,000/1,000
Other Services
Consult a doctor: telephonic doctor ofice visits—no fee Included
New directions behavioral health: EAP Included
PHCS PPO discounts Included
X Dependent age: to the end of the calendar year which the child attains age 26
Medical Insurance Cost of Coverage—Essential Med Plan
Monthly Employee Cost Payroll Deduction (24x)
Employee only $41.26 $20.63
Employee + 1 $173.50 $86.75
Family $286.92 $143.46
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Essential Med Plan
Beneits
Preventive Care
Preventive beneits are covered at 100%; visit www.healthcare.gov for a complete list of beneits Covered at %100
no copay
Hospital Coninement
Day 1 beneit amount $750 per day x 1 day per year
Days 2+ beneit amount per day $500 thereafter
Maximum beneit 5 days per year
Additional surgical beneit $500 per day x 1 day per year
Additional anesthesia beneit $125 per day x 1 day per year
Outpatient
Physician ofice visit prepay $10
Beneit amount per visit $85 per day x 3 days per year
Accident maximum beneit amount per year Up to $1,000 per year, 80%
payable U&C, $0 deductible
Emergency room (sickness) beneit amount per visit $250 per day x 2 days per year
Surgery beneit amount per surgery $500 per day x 1 day per year
Anesthesia beneit amount per surgery $125 per day x 1 day per year
Diagnostic, x-ray, lab-beneit amount per test
Class I: laboratory—blood work, CMP, lipid panel $30 x 4 test days per year
Class II: x-ray, ECG, PAP/PSA tests, all other diagnostic $75 x 2 test days per year
Class III: ultrasound, mammogram $125 x 1 test day per year
Class IV: CT, PET, MRI $250 x 1 test day per year
Prescription
Retail—generic Rx copay (retail/mail order) $10/$30
Retail—preferred brand Rx copay (retail/mail order) Discount only
Monthly beneit maximum—individual/family $200/$400
AD&D
Accidental death and dismemberment beneit amount (employee/spouse/each child) $15,000/5,000/1,000
Other Services
Consult a doctor: telephonic doctor ofice visits—no fee Included
New directions behavioral health: EAP Included
PHCS PPO discounts Included
X Dependent age: to the end of the calendar year which the child attains age 26
Medical Insurance Cost of Coverage—Essential Med Plan
Monthly Employee Cost Payroll Deduction (24x)
Employee only $41.26 $20.63
Employee + 1 $173.50 $86.75
Family $286.92 $143.46
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