Retiree - Medicare Eligible Health Plan
Medicare Carveout Classic Summary of Health Plan Benefits
2012 January-December |
Major Plan Benefits |
Plan Benefits for Covered Services |
| Plan Benefits | Supplemental to Medicare Parts A & B | Applicable after Medicare Parts A & B benefits have been applied, less Medicare deductibles |
| Deductible | $140 (must be met before copayments or coinsurance apply). Plan deductible runs concurrent with Medicare deductibles | |
Out-of-Pocket Maximum
|
If you reach this maximum, no further out-of-pocket will be required of you for covered expenses during the year. Plan premiums, deductible, expenses above usual, customary and reasonable, as well as expenses for outpatient prescription drugs, except those covered by Medicare Part B, do not apply toward this maximum. |
$1,500 per calendar year |
| Lifetime Maximum Benefit | Unlimited | |
Preventative Care
|
• Office visits in conjunction with an illness or injury |
80% after Deductible |
• Allergy Injections |
80% after Deductible |
|
| • Diagnostic tests, lab and x-rays | 80% after Deductible | |
• Preventative Care |
80% after Deductible | |
Hospital Services
|
• Inpatient hospital care |
80% after Deductible |
• Preadmission testing |
80% after Deductible |
|
• Outpatient hospital care |
80% after Deductible |
|
| • Ambulatory surgical care | 80% after Deductible | |
| Hospital Services | • Emergency Care (emergency room, emergency services) | 80% after $75 copayment waived if admitted) |
Other Medical Services
|
• Physical therapy, respiratory, occupational, or speech therapy | 80% after Deductible |
| • Home health services | 80% after Deductible | |
| • Durable medical equipment | 80% after Deductible | |
| • Oxygen | 80% after Deductible | |
• Skilled nursing facility |
80% after Deductible |
|
| • Ambulance | 80% after Deductible | |
| • Immediate care facility | 80% after Deductible | |
Mental Health |
• Inpatient hospital care |
80% after Deductible |
| • Outpatient care | 80% after Deductible | |
Substance Abuse |
• Inpatient hospital care |
80% after Deductible |
| • Outpatient care | 80% after Deductible | |
| *Inpatient hospital admissions do not require prior authorization. However, notification of hospital admissions is requested. | ||
