HEALTH INSURANCE

Benefit Outline for CPC Indemnity Plan

 

Benefits
Lifetime Medical Maximum

$1,000,000 Lifetime Maximum
Medical Deductible--3 per Family Maximum

$500 per person
Out of Pocket Maximum

$2,000
Co-Insurance Level

80%
Physicians Office Visit

80% after deductible
Diagnostic X-ray & Lab Work Performed in the Physicians Office

80% after deductible
Allergy Shots (injections)

80% after deductible

Preventative Care

  • Well Child Care & Immunizations (birth to age 2)
  • Annual Pap Smears
  • Mammogram Screening & Prostate Screening

80% after deductible
HOSPITAL AND OTHER CHARGES
Hospital Room & Board

80% after deductible
Emergency Room Charges

80% after deductible
Maternity Services

80% after deductible
Surgery

80% after deductible
Anesthesiologist, Radiologists, Pathologists

80% after deductible
MENTAL HEALTH, SUBSTANCE ABUSE
Inpatient

80% after deductible
Outpatient

80% after deductible
PRESCRIPTION DRUGS AT PARTICIPATING PHARMACIES

Retail Card Service--Unicare Prescription Drug Plan (including diabetic supplies)

Mail Order Drugs--Precision Rx (including diabetic supplies)

$15 Generic/$30 Brand/$40 non-formulary drug co-pay (34 day supply)

$30 Generic/$60 Brand/$80 non-formulary drug co-pay (90 day supply)

The following expenses will NOT apply toward satisfaction of the Out-of Pocket Maximum

  • Calendar Year Deductible
  • Network Co-Payment
  • Outpatient Treatment of Mental Illness, Alcohol and/or Substance Abuse
  • Any Cost Containment Provision Penalty
  • Charges in excess of Reasonable and Customary for Out-of-Network Benefits
  • $400 Annual In-patient Deductible Applies to Both PPO and Non-PPO Hospital Admissions (Waived for Newborn Children)

 

HOME BENEFITS INSURANCE

For more information, contact Robert Heflin

Page updated on April 6, 2004

Information updated on March 25, 2003

Pages maintained by Elinor Swindle Brown


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