|
MEDICAL |
CATASTROPHIC BENEFIT (HERITAGE NETWORK) |
| Annual Deductible |
$5,000 per person;
$10,000 per family |
|
Coinsurance (Plan Pays) |
In-Network: 100% after deductible
Out-of-Network: 80% after deductible |
|
Annual Out-of-Pocket Limit
(deductible and coinsurance) |
In-Network: $5,000
Out-of-Network: No limit |
| Annual Maximum Benefit |
$2,000,000 per person |
| Office Visit (OV) Benefit |
In-Network: Subject to deductible and coinsurance
Out-of-Network: Subject to deductible and coinsurance |
|
Inpatient Services
(Professional and Facility) |
In-Network: Subject to deductible and coinsurance
Out-of-Network: Subject to deductible and coinsurance |
| Outpatient Facility Services |
In-Network: Subject to deductible and coinsurance
Out-of-Network: Subject to deductible and coinsurance |
| Emergency Care |
Subject to In-Network deductible and coinsurance |
|
Preventive Care
- Preventive Office Visits
- Preventive Diagnostic Services and Immunizations
|
Paid at 100% with no deductible |
| Diabetes Health Education |
Covered at 100% with no deductible |
| Mammography |
In-Network: Paid at 100% with no deductible
Out-of-Network: Subject to deductible and coinsurance |
|
Mental Health
- Inpatient
- Outpatient |
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance |
|
Rehabilitation
- Inpatient
- Outpatient
|
Subject to Deductible and Coinsurance
(up to 30 days per calendar year)
Subject to Deductible and Coinsurance
(up to 45 visits per calendar year) |
| Chemical Dependency |
Subject to Deductible and Coinsurance |
| Home Health Care |
Subject to deductible and coinsurance
(130 visits per year) |
|
Hospice
( 6 month lifetime limit) |
Subject to deductible and coinsurance
(up to 10 days inpatient, 240 hours respite care) |
| Skilled Nursing Facility |
Subject to deductible and coinsurance
(60 days per year) |
| Acupuncture |
Subject to Deductible and Coinsurance
(12 visits per year) |
| Spinal Manipulations |
Subject to Deductible and Coinsurance |
Medical Supplies (MS),
Medical Equipment (ME),
Orthotics (OR),
Prosthetics (PR) |
Subject to Deductible and Coinsurance |
| Round-trip Air Transportation |
Up to 3 round-trips per year for medically necessary services that cannot be provided locally, subject to deductible and coinsurance |
| Transplants |
In-Network only |
|
Hearing Benefit
- Routine Exam
- Hearing Hardware |
$800 exam and hardware benefit limit every 3 years
Covered at 80% with no deductible
(1 exam every 3 years)
Covered at 80% with no deductible |
|
PRESCRIPTION DRUG |
CATASTROPHIC BENEFIT |
| Retail Copay |
Subject to medical deductible and coinsurance |
| Mail-Order Copay |
Subject to medical deductible and coinsurance |
|
DENTAL |
Not covered |
|
VISION |
Not covered |
