Mark III Employee Benefits - Polk County, NC

MAXIMUM LIFETIME BENEFIT AMOUNT	$1,000,000
Note: The maximums listed below are the total for Network and Non-Network expenses. For example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum is 60 days total, which may be split between Network and Non-Network providers.
	NETWORK PROVIDERS	NON-NETWORK PROVIDERS
DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person Per Family Unit The Calendar Year deductible is waived for the following Covered Charges: Preadmission testing PPO Wellness Benefit	$500 $1,500 (three persons)	$1,000 $3,000 (three persons)
COPAYMENTS Physician Visits Primary Specialist Hospital Emergency Room	$25 $35 N/A $50	N/A N/A $250 $50
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR Per Covered Person Per Family Unit The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%: • Deductible(s) • Outpatient mental treatment charges • Inpatient mental treatment charges • Outpatient substance abuse treatment charges • Inpatient substance abuse treatment charges • Cost containment penalties • Copayments	$2,500 $7,500 (three persons)	$3,500 $10,500 (three persons)
COVERED SERVICES Hospital Services Room and Board Intensive Care Unit Emergency Room Outpatient Facility Skilled Nursing Facility Physician Services Inpatient visits Office visits Surgery Home Health Care Outpatient Private Duty Nursing Hospice Care Bereavement Counseling Ambulance Service Jaw Joint/TMJ Wig After Chemotherapy Occupational Therapy Speech Therapy Physical Therapy Durable Medical Equipment Prosthetics Orthotics Spinal Manipulation Chiropractic Mental Disorders Inpatient Outpatient Substance Abuse Inpatient Outpatient Inpatient / Outpatient Combined Preventive Care Routine Well Adult Care Includes: office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x rays, laboratory blood tests and immunizations/flu shots (Performed or billed by physician’s office or independent facility) Frequency Limits for Mammogram Ages 35 through 39 - single Baseline mammogram Ages 40 through 49 - every two years Ages 50 and over - annually Routine Well Newborn Care Routine Well Child Care Includes: office visits, routine physical examination, laboratory blood tests, x-rays and immunizations through age 18 or age 25 if a full time student (Performed or billed by physician’s office or independent facility) Organ Transplants Pregnancy (Employee and Dependent Spouse only)	80% after deductible the semiprivate room rate 80% after deductible Hospital’s ICU Charge 80% after deductible and copayment 80% after deductible 80% after deductible, the facility’s semiprivate room rate within 14 days of a three day stay 70 days Calendar Year maximum 80% after deductible 80% after $25 or $35 copayment 80% after deductible 80% after deductible, $10,000 Lifetime maximum 80% after deductible 70 days Calendar Year maximum 80% after deductible 80% after deductible 80% after deductible 80% after deductible, $5,000 Lifetime maximum 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 50% after deductible 80% after deductible, 10 days Calendar Year maximum 80% after $35 copayment, 20 visits Calendar Year maximum 80% after deductible 50% after deductible $8,000 Calendar Year maximum, $16,000 Lifetime maximum 100%, $300 Calendar Year maximum 80% after deductible 100%, $300 Calendar Year maximum 80% after deductible 80% after deductible	50% after deductible and copayment, the semiprivate room rate 50% after deductible Hospital’s ICU Charge 50% after deductible and copayment 50% after deductible 50% after deductible the facility’s semiprivate room rate within 14 days of a three day stay 70 days Calendar Year maximum 50% after deductible 50% after deductible 50% after deductible 50% after deductible, $10,000 Lifetime maximum 80% after deductible 70 days Calendar Year maximum 50% after deductible 50% after deductible 80% after deductible 50% after deductible, $5,000 Lifetime maximum 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible, 10 days Calendar Year maximum 50% after deductible, 20 visits Calendar Year maximum 50% after deductible 50% after deductible $8,000 Calendar Year maximum, $16,000 Lifetime maximum 50% after deductible, $300 Calendar Year maximum 50% after deductible 50% after deductible, $300 Calendar Year maximum 50% after deductible 50% after deductible
PRESCRIPTION DRUG BENEFIT Pharmacy Option Generic drugs Copayment Formulary Brand Name drugs Copayment Non-Formulary Brand Name drugs Copayment Mail Order Prescription Drug Option Generic drugs Copayment Formulary Brand Name drugs Copayment Non-Formulary Brand Name drugs Copayment	$10.00 $25.00 $50.00 $30.00 $75.00 $150.00

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