Cumberland Presbyterian Church-Health Insurance Program PPO Outline

HEALTH INSURANCE

Benefit Outline for CPC PPO Plan

	In-Network Benefits	Out-of-Network Benefits
Lifetime Medical Maximum	$1,000,000 Lifetime Maximum
Medical Deductible--3 per Family Maximum	$500 per person	$500 per person
Out of Pocket Maximum	$2,000/Individual $4,000/Family	$3,000/Individual $6,000/Family
Co-Insurance Level	80%	70%
Physicians Office Visit	100% after $25 co-pay	70% after deductible
Diagnostic X-ray & Lab Work Performed in the Physicians Office	100%	70% after deductible
Allergy Shots (injections)	100% after $25 co-pay	70% after deductible
Preventative Care Well Child Care & Immunizations (birth to age 2) Annual Pap Smears Mammogram Screening & Prostate Screening	100% after $25 co-pay	70% after deductible
*HOSPITAL AND OTHER CHARGES*
Hospital Room & Board	80% after deductible	70% after deductible
Emergency Room Charges	80% after deductible	80% after deductible
Maternity Services	80% after deductible	70% after deductible
Surgery	80% after deductible	70% after deductible
Anesthesiologist, Radiologists, Pathologists	80% after deductible	70% after deductible
*MENTAL HEALTH, SUBSTANCE ABUSE*
Inpatient	80% after deductible	70% after deductible
Outpatient	50% after deductible	50% 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)

Medcall, Maternicall, Audio Library programs are included. See separate brochures.
Mental & Nervous/Drug Inpatient maximum is limited to 30 days per calendar year. Outpatient maximum is limited to 52 visits per calendar year.

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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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