The HMO provider network is available by clicking on this website address: Plan Provider Directory Search<b/>

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Kelly Cain
6 years ago
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1 GENERAL PROVISIONS Web Site Address Find a Plan Doctor or Facility Health Plan Telephone Number NCQA Accreditation Status The HMO provider network is available by clicking on this website address: Plan Provider Directory Search<b/> Commendable US News RATINGS (Quality Report) Consumer Assessment Prevention Treatment ANNUAL OUT-O F-POCKET LIMITATION Single Contract Multiple Party None None WebMD Benefits 2009 Page 1 of 7

2 ANNUAL OUT-O F-POCKET LIMITATION Contract HOSPITAL Semi - Private Room and Board Surgery, Inpatient and Outpatient Physician Inpatient Physical Therapy Functional Occupational Therapy OUTPATIENT Office Visits (Including Urgent Care) Physical Exams Active Employees - $25 copay Retiree - $10 copay Active Employees - $25 copay Retiree - $10 copay WebMD Benefits 2009 Page 2 of 7

3 OUTPATIENT Well-Baby Care Immunizations Allergy Tests, Injections Diagnostic Lab Outpatient Physical Therapy X-Ray & Imaging Active Employees - $25 copay Retiree - $10 copay Active Employees - $25 copay (if involves office visit) Retiree - $10 copay (if involves office visit) Active Employees - $25 copay (if involves office visit) Retiree - $10 copay (if involves office visit) 60 treatments per condition, per calendar year MATERNITY Prenatal, Delivery and Postnatal ; $10 copay on first office visit only EMERGENCY Emergency Care Active Employees - $100 copay (waived if admitted) Retiree - covered WebMD Benefits 2009 Page 3 of 7

4 AMBULANCE Ambulance EXTENDED FACILITIES Skilled Nursing Facility Home Health Care Private Duty Nursing PSYCHIATRIC Hospital Outpatient 45 days, renewable after 60 days Active: $25 co-pay, Retirees: $10 co-pay, 20 visits per calendar year SUBSTANCE ABUSE Hospital Outpatient 45 days, renewable after 60 days Active: $25 co-pay, Retirees: $10 co-pay, 35 visits per calendar year WebMD Benefits 2009 Page 4 of 7

5 PRESCRIPTION DRUGS Retail Pharmacies Mail Order Program HEARING Audiometric Examination Hearing Aid Frequency Limitation Active: $5 generic/$11 brand name copay per prescription Retiree: $5 generic/$10 brand name copay per prescription See Footnote #1 Active:$10 generic/$22 brand name copay per prescription, up to a 90 day supply. Retiree: $10 generic/$20 brand name copay per prescription See Footnote #2 ; $10 office visit copay 36 months w/hearing Aid VISION Vision Care Contact Information Examination Lenses and Frames , Active: ; $25 office visit copay Retiree: ; $10 office visit copay Standard plastic lenses ; $110 retail allowance for any frame and 20% discount off balance over allowance WebMD Benefits 2009 Page 5 of 7

6 VISION Contact Lenses $55 maximum allowance FOOT AND ANKLE Foot and Ankle Care - Outpatient Contact your plan for details on covered services OTHER Durable Medical Equipment Prosthetic and Orthotic Appliances Health Education & Special Programs SPECIAL SITUATIONS When Enrolled in Medicare Sponsored Dependent Coverage Plan coordinates with Medicare Available at subscriber's expense WebMD Benefits 2009 Page 6 of 7

7 #1: A Surviving Spouse with a retirement date prior to 1/1/04 has a $0 copay per prescription. #2: A Surviving Spouse with a retirement date prior to 1/1/04 has a $0 copay per prescription, up to a 90 day supply WebMD Benefits 2009 Page 7 of 7

EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan

2018 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare