2004
PPO Benefits-at-a-Glance |
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| Blue Card PPO | High
Option |
Middle
Option |
Low
Option |
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|
In-Network |
Out-of-Network* |
In-Network |
Out-of-Network* |
In-Network |
Out-of-Network* |
|
| Deductible |
None |
$500/person
or |
$250/person
or |
$1,000/person
or |
$500/person
or |
$1,000/person
or |
| Out-of-Pocket Maximum (Annual) |
$1,000/person
or |
$3,000/person
or |
$1,000/person
or |
$3,000/person
or |
$2,000/person
or |
$4,000/person
or |
| Lifetime Benefit Maximum |
Unlimited |
$2,000,000 |
Unlimited |
$2,000,000 |
Unlimited |
$2,000,000 |
| Physician Services (Office Visits) |
100%
after $20 copay |
70%
after deductible |
100%
after $25 copay |
60%
after deductible |
100%
after $30 copay |
60%
after deductible |
| Chemical Dependency - Inpatient (60-day maximum annual benefit) |
100%
after $200 copay per admission |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Chemical Dependency - Outpatient (45 visit maximum annual benefit) |
100%
after $20 copay |
70%
after deductible |
100%
after $25 copay |
60%
after deductible |
100%
after $30 copay |
60%
after deductible |
| Chiropractic Care (Maximum $1,500 annual benefit) |
100%
after $20 copay |
70% after
deductible |
100%
after $25 copay |
60% after
deductible |
100%
after $30 copay |
60% after
deductible |
| Emergency Care |
100%
after $100 copay |
100%
after $100 copay |
90%
after deductible |
90%
after deductible |
80%
after deductible |
80%
after deductible |
| Home Health Care |
100% |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Hospital - Inpatient |
100% after
$200 copay per admission |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Hospital - Outpatient |
100%
after $200 copay |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Lab & X-ray (outside of office visit) |
100% |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Prescription Drugs |
Retail Mail
Order (3 month supply) |
You must
pay the full amount of the prescription at the time of purchase and submit
the claim for reimbursement yourself. You will be reimbursed only the
discounted pricing that has been negotiated between Blue Cross and a participating
pharmacy for that prescription less your prescription drug copay. |
Retail Mail
Order (3 month supply) |
You must
pay the full amount of the prescription at the time of purchase and submit
the claim for reimbursement yourself. You will be reimbursed only the
discounted pricing that has been negotiated between Blue Cross and a participating
pharmacy for that prescription less your prescription drug copay. |
Retail Mail
Order (3 month supply) |
You must
pay the full amount of the prescription at the time of purchase and submit
the claim for reimbursement yourself. You will be reimbursed only the
discounted pricing that has been negotiated between Blue Cross and a participating
pharmacy for that prescription less your prescription drug copay. |
| Maternity |
100%
after $200 copay per admission |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Mental Health - Inpatient (60-day maximum annual benefit) |
100%
after $200 copay |
70%
after deductible |
90%
after deductible |
60%
after deductible |
80%
after deductible |
60%
after deductible |
| Mental Health - Outpatient (45 visit maximum annual benefit) |
100%
after $20 copay |
70%
after deductible |
100%
after $25 copay |
60%
after deductible |
100%
after $30 copay |
60%
after deductible |
| Adult Preventive Care & Well Child Care |
100% |
70%
after deductible |
100%
|
60%
after deductible |
100%
|
60%
after deductible |
| Urgent Care |
100%
after $35 copay |
100%
after $35 copay |
100%
after $35 copay |
100%
after $35 copay |
100%
after $35 copay |
100%
after $35 copay |
| *
You will be responsible for all charges above the usual and customary amount.
The information
about benefits included in this enrollment process is only a brief overview,
providing highlights of the eFunds welfare benefit plans. If there are
any differences between this overview and the official plan documents,
the plan documents will govern. eFunds reserves the right to amend or
terminate the welfare benefit plans for any reason and in its sole discretion,
and you would be subject to such amendments or termination. For more information
contact the Benefits Department. |
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