ODS Medical Plans Summary: Type of Plan : General Information:
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1 ODS Medical Plans Summary: General Information: Individual Deductible (plan year) $500 $500 $1,000 $1,000 Family Deductible (plan year) $300 $300 $600 $600 $1,500 $1,500 $3,000 $3,000 Individual Coinsurance Maximum (plan year) $500 $1,500 $1,000 $2,000 $2,000 $4,000 $2,000 $4,000 Family Coinsurance Maximum (plan year) N/A N/A N/A N/A N/A N/A N/A N/A Lifetime Benefit Maximum Member Coinsurance 10% 20% 20% 20% Covered Services: Hospital Benefit Inpatient Hospital Coinsurance Service authorization required 10% 20% 20% 20% Service Authorization Penalty Inpatient & Residential Inpatient Days Covered unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited Pre-admission Testing 10% 20% 20% 20% Inpatient Rehabilitative Hospital Care (30/60 days per calendar year) 10% 20% 20% 20% Emergency & Urgent Care Emergency Care ( if admitted) 0 per visit 0 per visit 0 per visit 0 per visit RN Advice for minor illnesses & injuries Urgent Care Visits Ambulance Transportation ($5,000 annual maximum) Skilled Nursing Facility Skilled Nursing Facility 60 per calendar year edoc edoc edoc edoc 20% 20% 20% 20% (ground or air ambulance) (ground or air ambulance) 10% (ground or air ambulance) 20% (ground or air ambulance) 10% 20% 20% 20%
2 Physician & Professional Services Office, Home or Hospital visit Outpatient Rehabilitation (physical, occupational and speech therapy - 30/60 days per calendar year) 20% 20% 20% 20% Anesthesiologist 10% 20% 20% 20% Ambulatory & Outpatient Hospital Services Outpatient Surgery 10% 20% 20% 20% Diagnostic X-rays & Laboratory Tests 10% 20% 20% 20% Chemotherapy 10% 20% 20% 20% Radium, Radioisotopic, X-Ray Therapy and Kidney Dialysis 10% 20% 20% 20% Imaging Procedures 10% 20% 20% 20% Preventive Healthcare Well Child Exams Newborn through age 17 Childhood Immunizations Adult Immunizations (flu and others as indicated) Routine Adult Physical Exams Age 18 and above Routine Mammograms subject to schedule Pap Smear Prostate Screening - Age 50 and over Colon Cancer Screenings Age 50 and over subject to schedule Cardiovascular screenings Hearing Evaluations
3 Family Planning Tubal ligation 10% 20% 20% 20% Vasectomy 10% 20% 20% 20% Contraceptive Devices 10% 20% 20% 20% Maternity/Newborn Care Outpatient Maternity Care 10% 20% 20% 20% Midwife Delivery (only if also a licensed nurse practitioner) 10% 20% 20% 20% Inpatient Delivery 10% 20% 20% 20% Newborn Circumcision 10% 20% 20% 20% Newborn Nursery Care 10% 20% 20% 20% Other Care/Treatments Allergy Testing 10% 20% 20% 20% Allergy Injections 10% 20% 20% 20% Therapeutic Injections 10% 20% 20% 20% Injectable Medication (administered in provider s office) 10% 20% 20% 20% Biofeedback Therapy 10% 20% 20% 20% 10 visits per lifetime 10% 20% 20% 20% Inborn Errors of Metabolism 10% 20% 20% 20% Cochlear Implants service authorization required 10% 20% 20% 20% Cosmetic and Reconstructive Surgery (medically necessary - service 10% 20% 20% 20% authorization required) Maxillofacial Prosthetic Services (medically necessary) 10% 20% 20% 20% Temporomandibular Joint Syndrome ($3,000 lifetime maximum) 10% 20% 20% 20% Special Dental Care (injury to natural teeth or jaw) 10% 20% 20% 20% Transplants (service authorization required) $0 $0 $0 $0 Therapeutic Abortions 10% 20% 20% 20% Podiatry Services (medically necessary) 10% 20% 20% 20%
4 Hospice Care (maximum benefit of,000) Hospice Home Care 10% 20% 20% 20% Hospice Inpatient Care 10% 20% 20% 20% Other Services Home Healthcare (daily limitations/140 visits per year) 20% 20% Respite Care (limited to 170 hours of care in three months) 10% 20% 20% 20% Infusion Therapy (service authorization required) 10% 20% 20% 20% Prosthetic & Orthotic Appliances (medically necessary) 10% 20% 20% 20% Non-prescription Enteral Formula for Home Use (medically necessary) 10% 20% 20% 20% Supplies, Appliances and Durable Medical Equipment (subject to 10% 20% 20% 20% limitations) Benefits for Chemical Dependency Deductible per Confinement 10% 20% 20% 20% Deductible per Day 10% 20% 20% 20% Detoxification 10% 20% 20% 20% Inpatient Treatment 10% 20% 20% 20% Outpatient Office Visits 20% 20% Treatment for Mental Illness Deductible per Confinement 10% 20% 20% 20% Deductible per Day 10% 20% 20% 20% Inpatient Treatment 10% 20% 20% 20% Outpatient Office Visits 20% 20% Group Therapy Mental Health Residential Care (45 days per calendar year) 20% 20% 10% 20% 20% 20%
5 Alternative Care (Combined maximum benefit of ) Chiropractic Care 10% 20% 20% 20% Acupuncture/Acupressure 10% 20% 20% 20% Naturopath 10% 20% 20% 20% Health & Wellness Online Health & Lifestyle Information - Reference edoc and MyOEBB.org ODS Pharmacy Plan Summary: Deductible: None Annual Copay / Coinsurance Maximum: $1,000 Retail (31 day supply) Mail Order (90 day supply) Generic Preferred $5.00 $ $50.00 Non-Preferred 50%, $50.00 max 50%, 0.00 max
6 GENERAL EXCLUSIONS FOR ODS MEDICAL PLANS: Behavior Modification Benefits Not Stated Charges Over the Maximum Plan Allowance Comfort and First-Aid Supplies Cosmetic/Reconstructive Surgery Counseling or Treatment in the Absence of Illness Custodial Care Dental Examinations and Treatment; Orthodontia Dental implants Experimental or Investigational Procedures Faith Healing Family Planning (vitro, etc.) Financial Counseling Services Food Services Gender Changes Genetic Engineering Growth Hormones Guest Meals in a Hospital or Skilled Nursing Facility Hearing Aids Homemaker or Housekeeping Services Non-terminal Hospice Services Immunizations (for travel) Infertility Inmates Legal Counseling Massage or Massage Therapy Mental Examination and Psychological Testing and Evaluations Mental Retardation/Learning Disabilities Missed Appointments Motor Vehicle Coverage and Other Insurance Liability Necessities of Living Nutritional Counseling Over the counter medications, vitamins and minerals Orthopedic Shoes Orthognathic Surgery Paraphilia Pastoral and Spiritual Counseling Personality Disorders Physical Examinations for employment, licensing or insurance Physical Exercise Programs Private Nursing Services Reports and Records Services Otherwise Available Services Provided by a Member of Your Immediate Family Services Provided by Volunteer Workers Service Related Conditions (armed forces of any country or from an Services Required As A Condition Of Maintaining A Valid Drivers Services and Supplies Provided for Obesity or Weight Reduction Sexual Disorders Support Education (e.g. AA, anger management, etc.) Supportive Environment Materials (e.g. handrails, ramps, benches, etc.) Surgery to Alter Refractive Character of the Eye (e.g. LASIK) Taxes TeleHealth and TeleMedicine Telephone Visits or Consultations, and Telephone Psychotherapy Telephones and Televisions in a Hospital or Skilled Nursing Facility Therapies related to developmental delay etc. Third Party Liability Transportation-non-emergent Treatment After Coverage Terminates Treatment for Admissions Prior to Coverage Treatment not Medically Necessary Treatment Prior to Enrollment Wigs, Toupees, Hair Transplants Work-Related Conditions
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