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HEALTH
BENEFITS
The
Pac-Advantage health care benefit package includes coverage for
physician office visits, outpatient services, hospitalization,
prescription drugs, mental health and substance abuse/chemical
dependency. Pac-Advantage health care benefits are
designed to be the same no matter which plan you choose,
although the co-payment will change depending on plan choice.
Pac-Advantage offers fourteen HMO and for point-of-service
plans.
This
matrix is intended to be used to help you compare coverage
benefits and is a summary only. The evidence of coverage
and plan contract should be consulted for a detailed description
of coverage benefits and limitations.
|
Benefit |
Standard |
Plus |
Preferred |
In Net |
Out Net |
| Deductible |
$0 |
$0 |
$0 |
$0 |
$500 |
| Life
Max. |
No Limit |
No Limit |
No Limit |
No Limit |
No Limit |
|
OutPocketMax.
Indiv./Family |
$2000
$4000 |
$2000
$4000 |
$2000
$4000 |
$2000
$4000 |
$5000
$10,000 |
| Office Visits |
$15 |
$10 |
$5 |
$10 |
30% |
| PreventiveCare |
$15 |
$10 |
$5 |
$10 |
no cover |
| Parent/Baby Care
(0-2yrs) |
$5 |
$5 |
$5 |
$5 |
no cover |
| Infertility |
50% |
50% |
50% |
50% |
no cover |
| Lab&Radiology |
$0 |
$0 |
$0 |
$0 |
no cover |
| OutPat.Surgery |
$100 |
$75 |
$50 |
$75 |
30% |
| Inpatient
Benefits |
$225 Per
Admission |
$100 Per
Admission |
$100 Per
Admission |
$100 Per
Admission |
30% |
| Nursing Care |
$100 Per
Admission |
$0 |
$0 |
$100 |
30% |
| Emergency
Coverage |
$50 if not
admitted |
$50 if not
admitted |
$50 if not
admitted |
$50 if not
admitted |
$50 if not
admitted |
| Ambulance |
$0 |
$0 |
$0 |
$0 |
$0 |
| Drug Coverage |
$10/$20 |
$10/$15 |
$5/$15 |
$10/$15 |
no cover |
| Mail Order |
$20/$40 |
$20/$30 |
$10/$30 |
$20/$30 |
no cover |
| Medical Equip. |
$0 |
$0 |
$0 |
$0 |
no cover |
| Mental Pat.
(10day max.) |
$100 Per
Admission |
$0 |
$0 |
$100 Per
Admission |
no cover |
| Outpatient (20
visit max/yr.) |
$20/20
visits or approved alternative |
$20/20
visits or approved alternative |
$20/20
visits or approved alternative |
$20/20
visits or approved alternative |
no cover |
The Pac-Advantage care benefit
includes coverage for examinations, eyeglass lenses and frames,
and contact lenses.
| Benefit
Summary |
VSP |
AVP |
VSP |
AVP |
| |
For Services
Provided In-Network |
For Services
Provided In-Network |
Out of Network
Reimbursement Schedule |
Out of Network
Reimbursement Schedule |
| Exam. Plus:
Every 12 months |
$25 co-pay |
$25 co-pay |
$35 allowance |
Emergency
service as described |
| Exam
Preferred: Every 12mo |
$10 co-pay |
$10 co-pay |
$35 allowance |
Emergency
service as described |
| Mat Spec Lens
Plus: Every 24 months |
$25 co-pay |
$25 co-pay |
$34-single
$51
bifocal
$68
trifocal
$100
LENT |
Emergency
service as described |
| Mat Spec Lens
Preferred: Every 12 months |
$20
co-pay |
$20 co-pay |
$34-single
$51
bifocal
$68
trifocal
$100
LENT
|
Emergency
service as described |
| Frames Plus:
Every 12 months |
$75 allowed |
$35 allowed
toward wholesale |
$38.25 |
Emergency
service as described |
| Preferred:
Every 12 months |
$75 allowed |
$35 allowed
toward wholesale |
$38.25 |
Emergency
service as described |
The
Pac-Advantage dental benefit package includes coverage for
diagnostic and preventive care services, restorative care,
specialty care and orthodontia.
| BENEFIT PLANS |
Prepaid |
Fee-For-Service |
In-Network |
Out-Network |
|
Preventive
& Diagnostic |
$0-cleaning,
exam, diag.
$5-panoramic/
full mth x-ray, sealant
$10-treatment
$15-emergency
$30-specialist
$50-space
maintainer |
100% |
100% |
50% |
| Basic Care |
Filings:
$4-22 Periodonties $15-80
Oral
$15-80 |
80%
w/exceptions |
80%
w/exceptions |
50% |
| Major Care |
Crown-Bridge $10-200 |
50% |
50% |
50% |
| Orthodon |
$350 per mem,
plus $1150 child/$1500 aduls. Active treat over 24
months sub. to $50/month co-payment |
50%
$1500
life max |
50%
$1500
life max
|
50%
$1500
life max
|
| AnnUMax |
none |
$1,000 exclus.
of Orthodon |
$1,500 exclus.
of Orthodon |
$1,000 exclus.
of Orthodon |
| AnnUDedct |
none |
$50/150 fam |
$50/150 fam |
$50/150 fam |
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