2013 Employee Benefits Guidebook - Administration Home

STANDARD MEDICAL EPO BENEFITS SUMMARY
PARTICIPATING
PROVIDERS
CALENDAR YEAR
ANNUAL LIMIT $2,000 ,000
NON-PARTICIPATING
PROVIDERS
DEDUCTIBLE, PER CALENDAR YEAR
Per Covered Person $2,000 Not Covered
Per Family Unit $6,000 Not Covered
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR
Per Covered Person $8,000 Not Covered
Per Family Unit $16,000 Not Covered
The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at
which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless
stated otherwise.
The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.
Copayments
COVERED CHARGES
Hospital Services
Inpatient Room and Board 75% after deductible and $500
copayment per admission
semiprivate room rate
Intensive Care Unit 75% after deductible and $500
copayment per admission
Not Covered
Not Covered
Outpatient Facility Services
Hospital's ICU Charge
75% after $250 copayment per
visit
No deductible applies
Not Covered
Outpatient Physician services
75%, no deductible or
copayment applies
Note: The copayment will apply as long as services billed include one or more of the facility room charges:
Operating room, recovery room, procedures room, treatment room, and observation room.
Skilled Nursing Facility, Rehabilitation 75% after deductible the
Not Covered
Hospital and
Sub-Acute Facilities
facility's semiprivate room rate
Emergency Room Services
100% after $200 copayment per visit;
2013 Employee Benefit Guidebook
Updated August 2013