BENEFITS SUMMARY

In-Network Plan Benefits

In-Network benefits are subject to a copay when you visit a physician for service. The copay amounts are as follows:

Short-Term Rehabilitation (STR) — The Premier Plan contains a special lower copay which applies when Members seek STR therapy. This lower copay applies to visits to providers who treat Members with this therapy because the therapy frequently involves several visits and the completion of the course of therapy is often necessary in order to achieve the desired result. Physician visits for STR include visits for the following therapy:

There is a 60-visit annual limit that applies to all of the visits for the services listed above during the calendar year. For example, if you have 20 visits to an Occupational Therapist and 40 visits to a Physical Therapist in the same year, you will have reached the 60-visit limit.

The STR copay also applies for visits to a Network chiropractor. There is a separate 60-visit annual limit for chiropractor visits during the calendar year.

In addition, the STR copay applies to diagnostic radiology which includes:

There is no copay when you are hospitalized at an In-Network hospital or have a test or procedure in the outpatient department of an In-Network hospital. Visits to the emergency room of an In-Network hospital for routine (non-emergency) medical treatment are not covered.

Prescription drugs are subject to the copay which is applicable to the type of drug indicated in the Premier Plan Chart. If you have a prescription for a brand drug for which there is a generic equivalent drug, the generic drug will be issued instead unless the prescribing physician has indicated that substitution may not occur. In that case the cost of the prescription will be subject to the $500 deductible per family each calendar year. Click here for more information on generic drug substitution.