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Medical Expense / Hospital Indemnity
Reimbursement Plan Through PML
This coverage is designed to help
participants offset the cost of their healthcare costs. Some of
the benefits include first dollar coverage, no deductibles, and
no coinsurance. In addition, there are no pre-existing condition
limitations and maternity coverage is included. However, this
coverage is limited. It is not intended to be construed as major
medical coverage.
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| |
Premier |
Basic |
| Medical Benefits |
Reimbursable Amount |
Reimbursable Amount |
| Office Visit |
$60/ visit up to $360/ year |
$50/ visit up to $300/ year |
| Diagnostic / Lab / X-Ray |
$60/ visit up to $300/ year |
$30/ visit up to $300/ year |
| Wellness Care |
$150/ visit up to $150/ year |
$50/ visit up to $150/ year |
| Hospital Confinement |
$800/ day; $500 day max |
$100/ day; $500 day max |
| Intensive Care |
$1,600/ day first 30 days
$800/ day thereafter |
$200/ day first 30 days
$100/ day thereafter |
| Emergency Room |
$75/ visit up to $300/ year |
$75/ visit up to $300/ year |
| Accident |
$2,500/ occurrence |
$500/ occurrence |
| Substance Abuse Care |
$400/ day up to 30 days/ year |
$50/ day up to 30 days/ year |
| Mental Health Care |
$400/ day up to $5,000/ year |
$50/ day up to $5,000/ year |
| Surgical Benefits |
$1,000/ year |
N/A |
| Skilled Nursing Facility |
$350/ day up to 60 days/ stay |
$50/ day up to 60 days/ stay |
Prescription Drug Benefits By MemberHealth
Inc.
| Preferred Generic Drugs |
$5 for a typical 30 day supply up
to $400/ month or $4,800/ year |
| Preferred Brand Name Drugs |
Discounts averaging 19% off the
wholesale price |
| Non-Preferred Generic & Brand
Name Drugs |
Discounts averaging 19% off the
wholesale price |
Life and Accidental Death and Dismemberment
| Employee |
$5,000 Life / AD&D (Amounts
reduce by 35% at age 65 and by an additional 35% each 5
year period thereafter. |
| Spouse |
$2,500 Life Only |
Generic Drug Card - Stand Alone Rx Benefit
* $5 for each 30 day supply of generic
prescriptions
* $15 for a 90 day supply of generic prescriptions through mail
order
* Discounts for preferred and non-preferred brand name and
generics
* $20 for a 30 day supply of bran name oral contraceptives
* $400 monthly max / $4,800 annual max
* Participants will receive a Preferred Drug List or Formulary
Other Covered Prescription Items:
Acne drugs (i.e. Retin-A) - Allergens -
Anabolic Steroids - Androgens - Anorexiants - Antiemetics -
Antineoplastics - Antivirals, Antiretrovirals, Antiinfectives
(i.e. Amebicides, Anthelminthics) - Antimalarials Antiprotozoals,
- Antituberculosis drugs and Leprostatics. - Atypical
Antipsychotics - Blood and Blood Plasma - Compound Drug -
Cosmetic Agents - Diagnostic Agents, reagents - Drugs used to
treat substance abuse (i.e. Revia, Antabuse) - Aricept - Brand
Name anti-Parkinson (i.e. Mirapex, Permax, Requip) -
Fertility/Infertility agents - Growth Hormone - Hair growth
stimulants (i.e. Propecia) - Immunosuppressive Agents -
Impotence Agents - Injectables - Insulin and Diabetic Supplies -
Minerals and Electrolytes - Non-Legend Drugs - Nutritional
Supplements and Vitamins - Oral Antifungals - Hemophiliac
factors - Smoking Cessation products - Topical Fluoride
preparations - Biologicals (including allergy tests) - Migraine
preps (i.e. triptans) - Brand Name NSAIDS (including Cox-II) -
Brand Name sleep agents (i.e. Ambien, Sonata)
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