SCHEDULE OF MEDICAL BENEFITS

Annual Deductibles:

Maximum Plan Benefit:

$350 Individual

(Includes All Other Maximums)

$1,050 Family (x3 members)

$1,000,000
         

Hospital Admission Co-pay:

Annual Out of Pocket Maximums:

PPO and Non-PPO

$100 per admission

(Excluding Deductible)

Outpatient Facility Co-pay:

PPO:

$2,400 Individual

PPO and Non-PPO

$50 per occurrence

  

$7,200 Family (x3 members)

Emergency Room Co-pay:

Non-PPO:

Unlimited

PPO and Non-PPO

$50 per occurrence

    

 

The Plan will pay benefits to Covered Persons for Covered Expenses as described herein in accordance with the Schedule of Benefits.  The Plan provides maximum benefits to the Covered Persons when they:

receive services or treatment from a provider who is a member of Private Healthcare Systems (“PHCS”)., a preferred provider organization; and

follow the procedures of the utilization management program described herein, which is administered by Spectrum Review Services, a utilization management organization.

If you have questions about participating providers or need help finding a participating provider, call PHCS at 1‑888-719-7427. A current list of PPO providers is available, without charge, through the PHCS website located at www.phcs.com. If you do not have access to a computer at your home, you may access this website at your place of employment.  If you have any questions about how to do this, contact the Human Resources Department.

If you have questions about the utilization management program, call Spectrum Review at 1-800-785-2539.

The Contract Administrator of the Plan is Boon-Chapman Benefit Administrators, Inc.  If you have other questions about the Plan (including questions about claims, premiums, and eligibility), call (512) 454-2681 or (800) 252-9653.

The following schedule summarizes the medical benefits of the Plan. Please refer to the remainder of the document for additional Plan provisions, which may affect your benefits.




Benefit

Annual

Plan

Additional Limitations

  

Description

Deductible

Pays

and Explanations

  
               

Accidental Injury Treatment

    

First $500 of covered expenses per occurrence.

  

PPO and Non-PPO

No

100%

  
               

Accidental Injury Treatment

    

In excess of $500 per occurrence.

  
 

PPO

No

80%

    
 

Non-PPO

No

50%

        
               

Acupuncture/ Acupressure

    

Calendar Year Maximum of $1500.

  
 

PPO

$20 co-pay

100%

  
 

Non-PPO

Yes

50%

  
               

Allergy Injections

   

Co-pay is applied with or without office visit charge.

  
 

PPO

$20 co-pay

100%

  
 

Non-PPO

Yes

50%

  
         

Allergy Testing and Serum

        
 

PPO

No

80%

  
 

Non-PPO

Yes

50%

  
         
       
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
               

Chiropractic Care

    

Calendar Year Maximum of $1,500

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
               

Diagnostic X-Ray & Lab

    

Applies to freestanding facility, inpatient and outpatient. Physician office charges are with office co-pay even if office visit is not charged with lab or x-ray.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  

Durable Medical Equipment

          
 

PPO

Yes

80%

    
 

Non-PPO

Yes

50%

  
             

Emergency Room Charges

    

Additional per-visit co-pay of $50. Co-pay is waived if the patient is admitted within 24 hours.
 

PPO

Yes

80%
 

Non-PPO

Yes

50%
             

Home Health Care Services

    

Calendar Year Maximum of 60 visits.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             

Hospice Services

    

Lifetime maximum of $10,000 combined for inpatient and outpatient. Includes Bereavement Counseling

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
           

Hospital Services

    

All Inpatient admissions must be pre-certified. There is a $250 penalty if you do not follow the procedures required by the utilization management program. This penalty does not apply to the out-of-pocket maximum.

Additional $100 co-pay for every inpatient admission

  

(Except Mental Health/Substance Abuse)

  
 

PPO

Yes

80%
 

Non-PPO

Yes

50%
             

INS (Immigration and Naturalization Service)

  

Covers all expenses incurred by any provider as required by the INS for routine physicals.

  
 

PPO

No

100%

  
 

Non-PPO

No

100%

  
     

Mental and Nervous Care/Serious Mental Illness

  

Lifetime Maximum for Inpatient & Day treatment care is a combined maximum of 45 days. Outpatient care is limited to 1 visit per day and 50 visits per lifetime.
 

PPO

Yes

100%
 

Non-PPO

Yes

100%
             

Occupational Therapy

    

Inpatient and outpatient

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
               

Outpatient Facility

    

Co-pay of $50 for every outpatient facility charge.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
         

Pain Management

    

Limited to 12 physician visits per calendar year.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             

Physical Therapy

    

Inpatient and outpatient

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             
 

Office visit includes all charges performed and billed by the physician’s office. PPO visit maximum of $100 paid by the plan, then charges apply to deductible and 80% coinsurance. Does not apply to Mental Health/ Substance Abuse.
 

PPO (up to $100 paid by plan)

$20 Co-pay

100%
 

PPO (over $100)

Yes

80%
 

Non-PPO

Yes

50%
             
         
 

PPO

Yes

80%

      
 

Non-PPO

Yes

50%

      
             
   

See “Prescription Drug Card Program” for more details.

Retail

    
 

Generic

$10 co-pay

100%

    
 

Brand Name

$25 co-pay

100%

  

Mail Order (90-day supply)

          
 

Generic

$20 co-pay

100%

    
 

Brand Name

$50 co-pay

100%

  
             

Private Duty Nursing

    

Limited to 60 visits per calendar year.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
         

Prosthetic Devices

        
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             

Routine Care – Annual Physical

    

Calendar year maximum of $450. Includes well woman, well man and well child visits, colonoscopy, hearing and vision tests, immunizations and flu shots.
 

PPO

$20 co-pay

100%
 

Non-PPO

$20 co-pay

100%
       

Routine Care – Mammogram

    

One exam annually, if not routine covered as All Other Expenses.
 

PPO

No

100%
 

Non-PPO

No

100%
         

Routine Care – Stress Tests

    

One test annually.
 

PPO

No

100%
 

Non-PPO

No

100%
         

Routine Newborn Care

    

Paid under mother’s charges and mother’s deductible.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             

Second Surgical Opinion

        
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
             

Skilled Nursing or Convalescent Facility

    

Facility’s semiprivate room rate within 14 days of a 3-day stay. Calendar year maximum of 60 days.

  
 

PPO

Yes

50%

  
 

Non-PPO

Yes

50%

  
             

Sleep Disorder

    

Only if approved as medically necessary.

  
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
           

Speech Therapy

        
 

PPO

Yes

80%

  
 

Non-PPO

Yes

50%

  
           

Yes

100%

  

Yes

100%

  
           

Surgery (Physician Fees)

    

Assistant surgeon’s covered charge will not exceed 20% of the surgeon’s UCR allowable.
 

PPO

Yes

80%
 

Non-PPO

Yes

50%
           

TMJ Treatment

Not Covered

  
           

Transplants

    

First $1500 paid at 100%.
 

PPO

Yes

80%
 

Non-PPO

Yes

50%
           

All Other Covered Expenses

        
 

PPO

Yes

80%

    
 

Non-PPO

Yes

50%