non-medicare eligible MemberS

Lifetime Maximum

• If eligible before April 1, 2006, with continuous coverage: $1,000,000 per person
• If eligible on or after April 1, 2006, with continuous coverage for:

• Less than one year

$100,000 per person

• One year, but less than two years

$200,000 per person

• Two years, but less than three years

$300,000 per person

• Three years, but less than four years

$400,000 per person

•  Four years, but less than five years

$500,000 per person

•  Five or more years

$1,000,000 per person

Calendar Year Maximum

$250,000 per person

Calendar Year Deductible

$250 per person; $500 family maximum

Coinsurance (unless noted otherwise)

After deductible, Plan pays:

90%

80%

Calendar Year Out-of-Pocket Maximum

$3,200 per person (including the deductible)
$6,400 family (including the deductible)

Hospital Expense Benefits*

Plan pays 100%, up to Usual and Customary amount charged

Plan pays 100%, up to Usual and Customary amount charged

Surgical Expense Benefits*

Plan pays 20% of Usual and Customary amount charged

Plans pays 100%, up to Usual and Customary amount charged

Physician Expenses

Plan pays 20% of Usual and Customary amount charged

Plans pays 20% of Usual and Customary amount charged

Precertification Penalty

10% of covered expenses

Physical Exam Benefit

Plan pays 100%; no deductible

$400 per person

Well Child Care Benefits

Plans pays 100%; no deductible

$750 per Dependent child

$400 per Dependent child per calendar year (limited to two visits per calendar year)

$200 per Dependent child per calendar year

Home Health Care Maximum*

After deductible, Plan pays up to $100 per hour for up to 4 hours per day for up to 21 days per calendar year

Morbid Obesity

After deductible, Plan pays 50% up to $15,000 per person per lifetime for surgical treatment

Cranial Prosthesis (Wig)

After deductible, Plan pays 80% up to $400 per person per lifetime

Chiropractic Benefits

After deductible, Plan pays 80% up to $1,500 per person per calendar year

Prescription Diet Medications

After deductible, Plan pays 80% up to $1,000 per person per calendar year

Behavioral Health Benefits

After deductible, Plan pays 80%

12 days per person calendar year

24 visits per person per calendar year

2 treatment programs per person per lifetime

$10,000 per person per lifetime; $5,000 per Dependent Child per calendar year

$25,000 per family per lifetime

Plan pays 100% up to $250 for one course of treatment when recommended by MAP

Elective Sterilization (Employee/Spouse)

After deductible, Plan pays 80% up to $400 per male or $800 per female per lifetime

Organ Transplant Benefit

After deductible, Plan pays 80%