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| SERVICE TYPE | IN-NETWORK | OUT-OF-NETWORK | ||||||||
| CALENDAR YEAR DEDUCTIBLE | $500, 1000, 2,000, 3000, 5000 | $1000, 2,000, 3000, 4,000, 6, 000 | ||||||||
| (MAXIMUM 3X FAMILY) | (WITH CO-PAY/DRUG CARD) | (WITH CO-PAY/DRUG CARD) | ||||||||
| $250 (NO CO-PAYS/DRUG CARD) | $500 (NO CO-PAYS/DRUG CARD) | |||||||||
| OUT-OF POCKET PER CAL YR | PLAN 1 - $500, 1,000, 2,000 | $2,000, 4,000, 8,000 | ||||||||
| (2X FAMILY PLUS DEDUCTIBLE) | PLAN 2 - $1,000, 2,000, 4,000 | $2,500, 5,000, 10,000 | ||||||||
| COINSURANCE PERCENTAGES | PLAN 1 - 90% | 60% | ||||||||
| PLAN 2 - 80% | 50% | |||||||||
| PHYSICIAN OFFICE | PLAN 1 - $25 | DEDUCTIBLE+CO-INS | ||||||||
| INCLUDES X-RAY & LAB | PLAN 2 - $35 | DEDUCTIBLE+CO-INS | ||||||||
| DIABETES SUPPLIES | * IN-NETWORK OV 100% AFTER | |||||||||
| ALLERGY INJECTIONS | CO-PAY UP TO $200 MAXIMUM | |||||||||
| CAT SCANS, MRI'S | EXCESS SUBJECT TO DEDUCTIBLE | |||||||||
| AND CO-INSURANCE | ||||||||||
| HOSPITAL SERVICES - INPATIENT | $150 CO-PAY | $300 CO-PAY | ||||||||
| DEDUCTIBLE + CO-INS | DEDUCTIBLE + CO-INS | |||||||||
| HOSPITAL SERVICES - EMERGENCY | $50 CO-PAY | $50 CO-PAY | ||||||||
| DEDUCTIBLE + CO-INS | DEDUCTIBLE + CO-INS | |||||||||
| OTHER COVERED CHARGES | DEDUCTIBLE + CO-INS | DEDUCTIBLE + CO-INS | ||||||||
| UNLESS OTHERWISE INDICATED | ||||||||||
| ADULT PREVENTATIVE SERVICES | CO-PAY $200 MAXIMUM | DEDUCTIBLE + CO-INS | ||||||||
| UPS PRESCRIPTION DRUG CARD | TIER 1 - $2 CO-PAY FOR GENERIC | |||||||||
| FOUR TIER FORMULARY | TIER 2 - $15 CO-PAY FOR COST EFFECTIVE BRAND | |||||||||
| 30 DAY MAXIMUM SUPPLY | OR 20%, WHICHEVER IS GREATER | |||||||||
| 90 MAIL ORDER SUPPLY | TIER 3 - $30 CO-PAY FOR HIGH COST BRAND DRUGS | |||||||||
| OR 30%, WHICHEVER IS GREATER | ||||||||||
| TIER 4 - MEMBER PAYS THE COST DIFFERENCE | ||||||||||
| BETWEEN GENERIC DRUG AND MULTIPLE SOURCE | ||||||||||
| BRAND DRUGS REGARDLESS OF EITHER MEMBER | ||||||||||
| OR PHYSICIAN REQUEST | ||||||||||
| 2 MILLION LIFETIME MAXIMUM | ORGAN TRANSPLANT LIFETIME MAXIUM $250,000 | |||||||||
| DME 20% CO-PAY | PHYSICAL THERAPY CALENDAR YEAR MAXIMUM $2,500 | |||||||||
| THIS IS ONLY A BRIEF DESCRIPTION OF BENEFITS AVAILABLE AND ALL COVERED SERVICES ARE NOT | ||||||||||
| LISTED. ALL ELIGIBLE SERVICES ARE SUBJECT TO THE DEDUCTIBLE AND CO-INSURANCE WITH THE EXCEPTION | ||||||||||
| OF THE COVERED IN-NETWORK OFFICE VISIT. THE OFFICE VISIT CO-PAY IS SUBJECT TO A $200 MAXIMUM | ||||||||||
| AND THE DIFFERENCE IS THEN APPLIED TO THE DEDUCTIBLE AND CO-INSURANCE. | ||||||||||
| ALPHA DATA SYSTEMS, INC. | ||||||||||
| 1545 WEST MOCKINGBIRD LANE, STE 6000 DALLAS, TX 75235 PHONE - 214-638-1488 FAX 214-638-1653 | ||||||||||
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