|
Medical Procedure
|
|
|
|
Not Eligible for Medicare
|
Enrolled in Medicare
"Secure Horizons"
|
| Annual Deductible |
None
|
None
|
| Annual Co-Payment Limit on Allowable Charges |
Plan pays 100% after co-payments reach $1,500 in a year ($4,500 for a family) |
None
|
| Overall Lifetime Maximum |
None
|
None
|
| Hospital - |
|
|
|
|
You pay $400 per admission |
Plan pays 100% |
|
|
Plan pays 100% |
You pay $5 per visit |
| Extended Care Facility (Skilled Nursing) |
You pay $400 per admission; 100 days maximum |
Plan pays 100% - 100 days maximum |
| Physician Services - Routine Physical |
|
|
|
|
You pay $20 per visit |
You pay $5 per visit |
Inpatient Surgery
|
Plan pays 100% |
Plan pays 100% |
Outpatient Surgery
|
Plan pays 100% (you pay $20 for office visit) |
Plan pays 100% (you pay $5 for office visit) |
Hospital Visits
|
Plan pays 100% |
Plan pays 100% |
Office Visits
|
You pay $20 per visit |
You pay $5 per visit |
| Diagnostic X-Ray and Lab |
Plan pays 100% (you pay $20 per office visit) |
Plan pays 100% (you pay $5 per office visit) |
| Durable Medical Equipment |
Plan pays 100% |
Plan pays 100% |
| Home Nursing Care |
Plan pays 100% |
Plan pays 100% |
| Physical Therapy |
You pay $20 per visit |
Plan pays 100% |
| Speech Therapy |
You pay $20 per visit; maximum of 50 visits or six months of treatment |
Plan pays 100% |
| Chiropractic Care |
Not covered
|
You pay $5 per visit; maximum of 12 visits per calendar year |
| Hearing Aids |
Not covered
|
$500 allowance every 24 months |
| Substance Abuse - |
|
|
|
|
Plan pays 100% ($25,000 annual maximum, $35,000 lifetime maximum) |
Plan pays 100%, maximum of 190 days per lifetime |
|
|
Plan pays 100% ($25,000 annual maximum, $35,000 lifetime maximum) |
You pay $5 per visit |
| Psychiatric Care - |
|
|
|
|
You pay $400 per admission; 30 days maximum |
Plan pays 100%, maximum of 190 days per lifetime in a Medicare approved psychiatric facility |
|
|
You pay $20 per visit; maximum of 30 visits per year |
You pay $5 per visit |
| Prescription Drugs |
Must be obtained at a participating HMO pharmacy |
|
|
You pay $15 per generic prescription and $35 per brand name prescription for a 30 day supply |
You pay $7 per generic and $14 per brand name prescription for a 30 day supply |
Maintenance (30 day supply or more thru the Mail Order)
|
Mail order - you pay 2 co-pays per prescription for a 90-day supply |
Mail order - You pay 2 co-pays per prescription for a 90-day supply |
| Vision Care |
You pay $20 for exam, lenses & frames not covered |
You pay $5 for exam, $125 materials allowance every 24 months |
| Dental Care |
Not covered
|
Not covered
|
| Ambulance |
Plan pays 100% |
Plan pays 100% |
| Emergency Room Care |
You pay $35 (co-payment waived if admitted to hospital) |
You pay $50 (co-payment waived if admitted to hospital) |
