Page 11 - 2013 Allied Printing Benefit & Notices

Allied Printing Co., Inc. 2013

Allied Printing HMO 1000 Plan Benefit Summary In Network
Deductible and Coinsurance Maximums
Deductible $1,000 Single / $2,000 Family
Coinsurance (Percentage copays) 50% for selected services / 10% for selected services
Annual Coinsurance Out-of-Pocket Max $1,500 Single / $3,000 Family for 10% services ONLY
Total Annual Out-of-Pocket Maximum* $2,500 Single / $5,000 Family
* Does not include fixed dollar copays or 50% coinsurance
Prescription Drugs
Generic (Tier I) – up to $15 copay; Brand (Tier II) – up to $50 copay.
Pharmacy (30 day supply)
Sexual Dysfunction Drugs – 50% coinsurance
Pharmacy or Mail Order (90 day supply) $30 Generic copay; $100 Brand copay
Preventive Services
Health Maintenance Exam 100% (one per calendar year)
Annual Gynecological Exam & PAP 100% (one per calendar year)
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year)
Mammography Screening 100% (one per calendar year)
Expanded Women’s Preventive Care 100% (one per calendar year)
Well-Baby and Child Care 100% (one per calendar year)
Immunizations – pediatric & adult 100% (one per calendar year)
Colonoscopy – screening or diagnostic 100% (one per calendar year)
Physician Office Visits
Office visits, Specialist visits $30 copay / $30 copay after deductible
Emergency Medical Care
Hospital Emergency Room (waived only if admitted) $150 copay after deductible
Facility Based Urgent Care Center $35 copay
Ambulance Services (air/ground) 90% after deductible
Diagnostic Services DRAFT
Lab & Pathology Tests Office Visit copay may apply per member, per visit
Diagnostic Tests & X-Rays 90% after deductible
High Tech Radiology Imaging 90% after deductible
Radiation Therapy 90% after deductible
Maternity Services
Pre and Post-natal Care $30 copay
Delivery & Nursery Care 100% after deductible for professional service (Also see Hospital Care)
Hospital Care
Semi-Private Room, Inpatient physician care, Hospital
services and supplies 90% after deductible
Inpatient Medical Care & Chemotherapy 90% after deductible
Alternatives to Hospital Care
Skilled Nursing Care 90% after deductible
Hospice Care 100% after deductible
Surgical Services
Surgery – includes related surgical services and medically 90% after deductible
necessary in or out-patient facility charges
Voluntary Sterilization 50% after deductible
Human Organ Transplants
Specified Organ Transplants 90% after deductible
Bone Marrow & Other Transplants 90% after deductible
Mental Health & Substance Abuse Treatment
In Patient Mental & Substance Abuse Treatment 90% after deductible
Out Patient Mental & Substance Abuse Treatment $30 copay after deductible
Other Services
Chiropractic Care – REFERRAL REQUIRED 90% after deductible
DME, P&O appliances 50%
O/P Occ/SP/Physical Therapy (60) $30 copay after deductible
Allergy Testing & Therapy 50% after deductible
Weight Reductions Procedures 50% after deductible
Infertility Counseling /Treatment 50% after deductible
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