PPO Plans - 2007-08

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Summary of Benefits 2007-08
This outline does not constitute the group policy and is not a contract of insurance.  It explains in simple language the essential features    
of the group benefits provided.  All rights with respect to the benefits of an insured person will  be governed solely by the group policy.    
Benefits PREMIER PLUS PREMIER STANDARD BASIC
Composite $1,115 $962 $885 $726
Employee Only $557 $481 $442 $363
Employee + 1 $1,059 $914 $841 $690
Employee + Family $1,394 $1,203 $1,106 $908
Single Medicare $368 $317 $292 $240
Maximum Lifetime  $6,000,000 $6,000,000 $6,000,000 $6,000,000

Calendar Year Deductible

  
PPO Individual $75 $250 $500 $1,000
Family $225 $750 $1,500 $3,000
Non PPO Individual $150 $500 $1,000 $2,000
Family $300 $1,500 $3,000 $6,000
Office Visit Copay        
PPO Individual $10 $15 $20 Subj. to ded./coins.
Non PPO Individual $20 Subj. to ded./coins. Subj. to ded./coins. Subj. to ded./coins.

Calendar Year Coinsurance (OOP Max. is in addition to the deductible)

        

PPO Individual

 20% to $400 10% to $1,500 20% to $3,000 50%to $5,000
Family 20% to $800 10% to $3,000 20% to $6,000 50%to $10,000
Non PPO Individual 40% to $1,200 30% to $4,500 40% to $9,000 60% to $20,000
Family 40% to $2,400 30% to $9,000 40% to $18,000 60% to $40,000
         
Pre-existing Limitation None      
Physician/Practitioner Office Visit See amounts above      
Routine Physical Exam PPO payable 100%.  Non-PPO subject to Deductible and Coinsurance.
Preventive Child Care/Year PPO payable 100%.  Non-PPO subject to Deductible and Coinsurance.
Immunizations Per CDC PPO payable 100%.  Non-PPO subject to Deductible and Coinsurance.  Foreign travel immunizations are excluded.  
In-patient Hospitalization Subject to Deductible and Coinsurance.
Out-patient Hospitalization Subject to Deductible and Coinsurance.
Surgery Subject to Deductible and Coinsurance.
Anesthesiologist Subject to Deductible and Coinsurance.  If surgeon is PPO, then anesthesiologist treated as PPO.
Skilled Nursing Subject to Deductible and Coinsurance. 100 days per calendar year.
Home Health Care Subject to Deductible and Coinsurance. 100 days per calendar year.
Hospice Care Subject to Deductible and Coinsurance. $10,000 Lifetime Maximum.
Bereavement Counseling Four sessions/$25 Maximum
Hospital Emergency Room $50 ER Deductible then Plan pays appropriate coinsurance percentage, PPO or Non-PPO.  ER Deductible applies per occurrence.  
Maternity Subject to Deductible and Coinsurance. Family coverage.
Bariatric Surgery Not covered      
Ambulance Subject to Deductible and Coinsurance. 
Chiropractic Office Visit $20 copay, 26 visits per Calendar Year    
Durable Medical Equipment Subject to Deductible and Coinsurance. 
TMJ Subject to Deductible and Coinsurance. $1,000 Lifetime Maximum.

Prescription Drugs

  

Retail:

 Receive up to a 31 day supply at a retail store:

Generic

 $7 copay on all Plans
Preferred Brand 25% to max of $35 on all Plans
Non-Preferred 45% to max of $70 on all Plans    

Mail Order:

 Receive up to a 90 day supply through TCSIG's mail order:
Generic $14 copay on all Plans
Preferred Brand $50 copay on all Plans
Non-Preferred $90 copay on all Plans      
Mental Health Pre-certification required for both Inpatient and Outpatient services
In-patient Hospitalization PPO Only      
Days Limitation 30 per yr/90 lifetime      
PPO Out-patient 50% to a $50 maximum      
Non PPO Out-patient 50% to a $25 maximum      
Cal Year Maximum 52 visits, 1 per day      
Chemical Dependency Calendar Year Max $10,000; Lifetime Max $20,000    
Copays and ER Deductibles do not apply toward annual Deductible or Coinsurance.      

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Phone:  (530) 822-5299 or Toll-Free (866) 822-5299

Last modified:  07-11-07

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This website created by:  TCSIG Staff