Washwick
PLANS

PLAN A
Prime HMO Standard

PLAN B
Select PPO Standard

PLAN C
Select PPO Standard

PLAN D
Select PPO
Standard
MONTHLY PREMIUM
(Domestic Partners Not Covered)

  NO LONGER AVAILABLE AS OF 9/1/2011
 

 


No Referrals Required
$  608.32  Single
$  1153.75 Employee & Child(ren)

$  1425.71  Two Person

$ 1862.34 Family

No Referrals Required
$  552.31  Single
$ 1046.20  Employee & Child(ren)

$  1291.29 Two Person

$  1687.94  Family

 

No Referrals Required
$ 497.71  Single
$  941.35  Employee & Child(ren)

$  1160.25 Two Person

$  1517.90  Family
Office Visits

$ 30 Copay for PCP 

& $50 Copay for Specialist

$ 30 Copay for PCP 
& $50 Copay for Specialist

$ 30 Copay for PCP 

& $50 Copay for Specialist

Lab, X-Ray, EKG

Incl in PCP Copay

Incl in PCP Copay

Incl in PCP Copay

EMERGENCY ROOM

$150 Copay

 $150 Copay

$150 Copay

Information on Deductibles

PLAN NO LONGER AVAILABLE 9/1/2011

All services that have deductibles:
the deductible plan year is
Calendar Year
9/1/11 to 12/31/11
1/1/12 - 8/31/12

All services that have deductibles:
the deductible plan year is
Calendar Year
9/1/11 to 12/31/11
1/1/12 - 8/31/12

All services that have deductibles:
the deductible plan year is
Calendar Year
9/1/11 to 12/31/11
1/1/12 - 8/31/12

HOSPITAL:
In Patient, Ambulatory Surgery, & Outpatient Facilities Services

In-Network: Ded. $2000/$4000 then 80% - Co-ins $5000/$10000 (does not incl ded); Out-of-Network: Ded. $4000/$8000 then 60% - Co-ins $10000/$20000 (does not included

 In-Network: Ded. $2000/$4000 then 80% - Co-ins $5000/$10000 (does not incl ded); Out-of-Network: Ded. $4000/$8000 then 60% - Co-ins $10000/$20000 (does not included)

In-Network: Ded. $3000/$6000 then 80% - Co-ins $10000/$20000 (does not incl ded); Out-of-Network: Ded. $6000/$12000 then 60% - Co-ins $20000/$40000 (does not included)

Rx DRUG CARD

$300 Deductible then $20/$30/$50 Non-Formulary

$100 Deductible then

$10 GENERIC ONLY

Not Covered
Ambulatory Surgery & Outpatient Facility Services

Subject to Deductible and Co-insurance Subject to Deductible and Co-insurance

Subject to Deductible and Co-insurance

Private Duty Nurse

Not Covered Not Covered

Not Covered
Skilled Nursing Facility 30 day limit Subject to Deductible and Co-Insurance 30 day limit Subject to Deductible and Co-Insurance 30 day limit Subject to Deductible and Co-Insurance
Home Health Care 40 Visits Subject to Deductible and Co-Insurance 40 Visits Subject to Deductible and Co-Insurance 40 Visits Subject to Deductible and Co-Insurance
In-Patient Therapies 30 days Subject to Deductible and Co-Insurance 30 days Subject to Deductible and Co-Insurance 30 days Subject to Deductible and Co-Insurance
Out-Patient Therapies $50 Copay, 30 visit limit $50 Copay, 30 visit limit $50 Copay, 30 visit limit
In-Patient Mental Health Care 30 days Subject to Deductible and Co-Insurance 30 days Subject to Deductible and Co-Insurance 30 days Subject to Deductible and Co-Insurance
In-Patient ALC/SA Detox 7 days Subject to Deductible and
Co-Insurance		 7 days Subject to Deductible and
Co-Insurance		 7 days Subject to Deductible and
Co-Insurance
In-Patient ALC/SA Rehab

$50 Copay, 60 visit limit

$50 Copay, 60 visit limit

$50 Copay, 60 visit limit
Out-Patient ALC/SA Rehab

$50 Copay, 60 visit limit

$50 Copay, 60 visit limit

$50 Copay, 60 visit limit
Out-Patient Mental Health $50 Copay, 40 visit limit $50 Copay, 40 visit limit $50 Copay, 40 visit limit
Dialysis Copay $20 Copay $20 Copay $20 Copay
Refractive Eye $25 Copay $25 Copay $25 Copay
Diabetic Supply Copay $30 Copay $30 Copay $30 Copay
Preventive Dental                                        Included Included Included
Infertility Not Covered Not Covered Not Covered
Optical

Eyeglasses/Contacts ($0/$25) every 12 Months Eyeglasses/Contacts ($0/$25) every 12 Months Eyeglasses/Contacts ($0/$25) every 12 Months

Dependents
(Domestic Partners Not covered)

Dep. Children to end of month in which they turn 26

Dep. Children to end of month in which they turn 26

-

Dep. Children to end of month in which they turn 26
Durable Medical Equip. Not Covered Not Covered Not Covered
Health Fitness Reimb. $200 reimbursement at the end of the annual membership $200 reimbursement at the end of the annual membership $200 reimbursement at the end of the annual membership


Rates & Benefits are for comparative purposes only. 
Actual rate & benefit info and details must come directly from the insurance carrier. 

This is only a summary of benefits. You will receive full details of coverage contained in the policy received directly from Insurance Company. If there is any conflict between the contents of this document/website and the policy from the Insurance Company, the Policy will govern in all cases.

$16 Administrative Fee Included.

Plans Effective 9/1/11 through 8/31/12