Plan Year 7/1/11 - 6/30/12 Plan Facts Cost

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Rehab: Outpatient coverageRehab: Inpatient coverage90% covered; facility; $12 copay for physicianOut of Network70% coveredIn Network$12 copayOut of Network70% coveredIn Network90% covered; facility; $12 copay for physicianOut of Network70% coveredDental implantsAccidental injury to teethSurgical removal of tumors, cysts, and impacted teethIn NetworkNot coveredOut of NetworkNot coveredIn Network90% covered; check with Plan about details forlimitations to oral surgeryOut of Network70% covered; check with Plan about details forlimitations to oral surgeryIn Network90% covered; removal of impacted teeth not coveredOut of Network70% covered; removal of impacted teeth not coveredRoutine vision examsRegular lenses and framesContact lensesIn NetworkNot coveredOut of NetworkNot coveredIn NetworkNot coveredOut of NetworkNot coveredIn NetworkNot coveredOut of NetworkNot coveredHearing evaluationsHearing aidsIn Network90% coveredOut of Network70% coveredIn Network
80% covered; limited to one hearing aid per ear everyfive years; digital aids limited to no more than theamount Plan would pay for analog aidsOut of Network70% covered; limited to one hearing aid per ear everyfive years; digital aids limited to no more than theamount Plan would pay for analog aidsAcupunctureChiropracticOutpatient physical therapyIn NetworkNot coveredOut of NetworkNot coveredIn NetworkNot coveredOut of NetworkNot coveredIn Network80% covered; must be medically necessary; checkwith Plan for details about benefit maximumsOut of Network70% covered; must be medically necessary; checkwith Plan for details about benefit maximumsOutpatient speech therapyOutpatient occupational therapyIn Network80% covered; must be medically necessary; limited toshort-term only; check with Plan for details aboutbenefit maximumsOut of Network70% covered; must be medically necessary; limited toshort-term only; check with Plan for details aboutbenefit maximumsIn Network80% covered; must be medically necessary; checkwith Plan for details about benefit maximumsOut of Network70% covered; must be medically necessary; checkwith Plan for details about benefit maximumsNoncustodial home health careIn Network100% covered; limited to 150 visits per calendar yearOut of Network70% covered; limited to 150 visits per calendar yearPrescribed care in noncustodial skilled nursing facilityIn Network90% covered; limited to 120 days per calendar yearOut of Network70% covered; limited to 120 days per calendar year
Page 3 and 4: Annual Rx out-of-pocket maximumReta
Page 5: 70% coveredOffice visit: Pre/postna
Page 9: Weight control programPrenatal care

Plan Year 7/1/11 - 6/30/12 Plan Facts Cost

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