Select Plus Plan

One plan of many....please call for pricing
BENEFIT IN-NETWORK OUT-OF-NETWORK
Deductible single
                 family 
Coinsurance
Max. out of pocket - single
                             family 
Lifetime Benefit		 None
None
None
Not applicable
Not applicable
Unlimited		 $1,000
$3,000
70%
$5000 (excluding deductible)
$10,000 (excluding deductible)
Unlimited
Prescription Drug Card

mail order is 2X copay

 $10 generic/$30 brand/$50 non-preferred Participating pharmacies only
Non notification deductible N/A 50% of covered expenses
Hospital Care
Semi private room & board
Anethesia
Physician services
Services and supplies
Lab tests/Diagnostic imaging
$500 copay per admittance
Deductible & Coinsurance
Physician's & other outpatient services
Exams (includes diagnostic lab tests)
Well child care(incl. immunizations)
Gynecological visits
Refractive vision exam (limited to one every 2 cal. years) (network only)

Routine Mammography ( subject to age schedule)

$20.00 copay
copay waived to age 19(NY only)
$20.00 copay
$20.00 copay


No charge

 Subject to deductibles & Coinsurance




Eye exam not covered out of network
Out Patient Diagnostic Services
Lab tests ( independent facilities)
Diagnostic Imaging
Allergy Diagnosis & treatment
Allergy Injections
Diabetic self management education
No charge
No charge
$20.00 co pay
No charge
$20.00 co pay
all at deductible & coinsurance
Emergency Care
Hospital Emergency Room

Urgent care facility
 ..
$50 copay

$35 copay/visit
 ...
$50 copay

Subject to deductible & Coinsurance
Ambulance
 No charge
 deductible & Coinsurance
Maternity Care
Prenatal & Post-natal care
$20 Copay after first visit


Subject to deductible & coinsurance

Outpatient Surgery
Physician and facility
$20 copay
Subject to deductible & Coinsurance
Therapy
Physical,Occupational & Speech
(20 visits per year)
Cardiac rehabilitation (20 visits per year)
Oxygen & Respiratory Therapy
 Chiropractic
Chemotherapy & Radiation
$20 copay
Deductible & Coinsurance
Home Health Care
Duration determined by via Care Coordination
No charge
75% after deductible
Outpatient Chemical Dependency
Individual therapy sessions (60 per year)
Group therapy sessions (60 per year)
(20 visits may be used for family counseling)

$10 copay
$5 copay

Deductible & coinsurance
Inpatient Chemical Dependency
Rehab - 30 days per year
Detox - 7 days per year
No charge
Deductible & Coinsurance
Mental Health Care
Outpatient - 30 visits per year
Group therapy sessions (30)
Inpatient 30 days per year
 $20.00 copay
$10.00 copay
100%
50% after deductible
50% after deductible
Deductible and coinsurance
Hospice Care (180 days)

No charge
 Not covered
Extended Care Facilities
60 days per year
 No Charge
Deductible & Coinsurance
100% if admitted from a hospital
Diabetic Supplies & Services
 No charge
 Deductible & Coinsurance
Durable Medical Equipment
 No charge
 Limited to $2,500 per year
Prosthetics
 No charge
 Deductible & Coinsurance
Infertility Services - Treatment & Diagnosis of underlying medical conditions
No Charge
Deductible & Coinsurance
Assisted Reproductive Technology
Artificial insemination
Introfertilization,GIFT,ZIFT
100% ($2,000 annual maximum)
Not covered
Not covered
Not covered
Where benefits are subject to day or visit limits, the maximums indicated represent the combine total of benefits available both in and out of network. In network services are available when provided, arranged or authorized by a Participating Physician. This is intended only as a general summary of benefits. More complete descriptions of benefits and the terms under which they are provided are contained in the Group Service Agreement/Certificate