Google
WWW SPEEA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

Traditional Medical Plan

  Service $15 Copay Subject to Deductible % Coverage (Network) Comments
1 Preventive checkup in physician's office No No 100% Periodic examination capped at $200
2 Treatment by physician in physician's office, home, or hospital as outpatient visit Yes No 100% after copay
3 Consultation - in physician office, home, or as hospital outpatient Yes No 100% after copay
4 Physician - inpatient hospital visit No Yes 95%
5 Hospital charges - prior to 7//1/04 No Yes 100%
6 Hospital charges - after 7//1/04 No Yes 95/100% 100% in hospitals meeting Patient Safety Standards
7 Prescriptions - filled at a pharmacy (34 days) No Yes 90/80/70%
8 Prescriptions - by mail order (up to 90 days) $10/30/60 Yes 100% after copay
9 Lab work - Physician office site of service (except for certain preventive care screening) No Yes 95%
10 Lab work - outside laboratory (except for certain preventive care screening) No Yes 95%
11 Lab work - Physician office site of service or outside laboratory – preventive care screening only No No 100%
12 Smoking cessation office based visit – consultation and/or treatment No No 100% $500 lifetime maximum applies
13 Allergy shot by MD or RN - Physician office site of service No Yes 95%
14 Immunization by MD or RN - Physician office site of service (except for scheduled immunizations for children) No Yes 95%
15 Scheduled immunizations by MD or RN for children - Physician office site of service (under preventive care benefit) No No 100%
16 Chemotherapy - Physician office site of service No Yes 95%
17 Office based surgery - Physician office site of service No Yes 95%
18 Physical therapy, occupational therapy, speech therapy - Physician office site of service No Yes 95%
19 Initial confirmation of pregnancy - Physician office site of service Yes No 100% after copay
20 Maternity checkup - Physician office site of service Usually included in global fee.
21 Chiropractor office visit – treatment Yes No 100% after copay
22 Mental health outpatient visit – treatment No Yes 80%
23 Substance abuse outpatient visit – treatment No Yes 95%
24 Home nursing care, hospice or skilled nursing facility No Yes 100%

Notes

Office co-pays do not count toward deductible

Monthly premiums do not count toward deductible

Maximum out-of-pocket expense limit applies to "covered expenses."

Expenses for smoking cessation, preventive checkups and other limited items are not capped by the maximum out-of-pocket limit.

Expenses for durable medical equipment are not capped by the maximum out-of-pocket limit.