(Documentation needed for enrollment.)
Effective January 1, 2008
Plan Features |
Benefit |
| Network -Local Area
Network
-Outside of the Sagamore Network Area |
Sagamore Plus
PHCS Healthy Directions |
| Co-pay In-Network -All other covered services except emergency room and office visits |
ISU Pays Employee Pays 80% 20% |
| Co-pay Out-of-Network - All covered services |
ISU Pays Employee Pays
50% 50% |
| Calendar Year Deductible | $250 individual / $750 family |
| Stop-Loss In-Network (Calendar Year Deductibles, office visit co-pays, emergency room co-pays, expenses processed under the dental plan or the prescription drug card plan are not included in the stop loss out-of-pocket expenses). |
$2,500 per
individual per calendar year $5,000 family aggregate |
| Stop-Loss Out-of-Network (Calendar Year Deductibles, expenses processed under the dental plan or the prescription drug card plan are not included in the stop loss out-of-pocket expenses). |
$7,500 per
individual per calendar year $15,000 family aggregate |
| Hospital Pre-admission Certification | $500 penalty for non compliance. 100% penalty for extended days |
| Lifetime Maximum | $2,000,000 per individual |
| Eligible Dependent Children | End of calendar year of child's 19th birthday; or if full time student, end of calendar year of child's 23rd birthday |
| Pre-Existing
Waiting Period
(can be waived with for each month of prior health coverage, up to the full 12 months, if enrolled with a group plan within 63 days of effective date of coverage. A certificate of creditable coverage must be provided within the first 60 days of employment, for each person covered, showing the number of months of prior coverage). |
Payment for treatment of any condition for which treatment was received within the 6 month period preceding the effective date of coverage is limited to $2,500 paid for each condition for the first twelve (12) months of coverage. (Does not pertain to maternity) |
Plan Features |
In-Network |
Out-of Network |
| Hospital Inpatient Room and Board -Semiprivate Room -Private Room if Medically Necessary or hospital has only private rooms -Specialty Care Unit (i.e. ICU; CCU) Ancillaries |
80 % of covered
charges No deductible |
50% of covered
charges $200 copay per confinement Subject to calendar year deductible |
| Hospital Outpatient | 80% of covered charges Subject to calendar year deductible |
50% of covered charges Subject to calendar year deductible |
| Skilled Nursing Facility -Room and Board -Semiprivate Room -Private Room if Medically Necessary or hospital has only private rooms -Ancillaries |
80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
| Inpatient Medical Visits -One visit per physician, per day, per diagnosis, including consultations |
80% of covered charges No deductible |
50% of covered
charges Subject to calendar year deductible |
| Surgery/Anesthesia | 80% of covered charges No deductible |
50% of covered charges Subject to calendar year deductible |
| Assistant
Surgeon (Not to exceed 20% of surgical allowance) |
80% of covered charges No deductible |
50% of covered charges Subject to calendar year deductible |
| Pre-Admission Testing | 80% of covered charges No deductible |
50% of covered charges Subject to calendar year deductible |
| Emergency Room -(for
life threatening accident or life threatening illness)
|
$100 copay No deductible $100 Copay |
50% of covered charges Subject to calendar year deductible 50% of covered charges |
| Office Calls/ Consultations | $15 per visit
copay No deductible |
50% of covered
charges Subject to calendar year deductible |
| Diagnostic Services | 80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
|
Mental Health and Substance Abuse Provider of services must be a psychiatrist (MD) or a psychologist who is a certified health service provider in psychology (PhD)or Licensed Mental Health Counselor (LMHC). |
80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
| Ambulance |
80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
| Therapy Services -Radiation Therapy -Chemotherapy -Dialysis -Respiratory/Inhalation Therapy
|
80% of covered
charges Subject to calendar year deductible
|
50% of covered
charges Subject to calendar year deductible
|
| Medical Aids (DME) (rental fees for eligible equipment not to exceed purchase price) Maximum amount payable of $2,500 per person per calendar year. |
80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
| Wellness Care - Well baby care -Immunizations for children -Physical examinations, including related diagnostic testing -Pap smears and annual gynecological check-ups -Cholesterol and triglyceride testing -Screening mammographies -Hemocult Test -Blood Tests -Prostrate Specific Antigen (PSA) -Ovarian cancer screening (CA 125) test -Hepatitis A, B, and C vaccines -flu & pneumonia vaccines |
office calls or
consultations $15 per visit copay no deductible all other covered services Maximum $600 paid per person |
all covered
services 50% of covered charges
Maximum $600 paid per person per calendar year |
| Home Health Care | 80% of covered
charges Subject to calendar year deductible |
50% of covered
charges Subject to calendar year deductible |
| Temporomandibular Joint (TMJ) Services - Office Calls or Consultations -Surgery -Other TMJ Services Maximum benefit paid is $1,000 per person per calendar year with a lifetime maximum of $3,000 |
$15 copay No deductible 80% of covered charges 80% of covered charges |
50% of covered
charges Subject to calendar year deductible 50% of covered charges |
| Plan Features | You Pay | Plan Pays |
| Prescription
Drugs* |
|
|
| -Generic |
$10 copay & 10% |
90% after copay |
| -Brand (No Generic) |
$20 copay & 20% |
80% after copay |
| -Brand chosen over Generic |
$20 copay & 50% |
50% after copay |
| -All other FDA approved prescription drugs |
100% after discount |
discount |
*As of 01/01/2008 prescription drug coverage is expanded to include oral
contraceptives, self-injectable drugs, smoking cessation aids, erectile dysfunction,
and weight loss drugs for morbid obesity.
**No reimbursement for prescriptions purchased without your prescription drug card
Maintenance drugs are limited to a 90-day supply. Mail order is voluntary for all maintenance drugs.