ALPHA CARE GOLD MEDICAL BENEFITS
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SERVICE TYPE |
PREFERRED
PROVIDER (In-Network) |
NON-PREFERRED
PROVIDER (Out-of-Network) |
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Calendar Year Deductible Maximum 3 per Family |
$250 No Co-Pay Benefits All subject to Deductible Plus Coinsurance (No Drug Card Benefit) $500, $1,000, $2,000 and $3,000 |
$500 No Co-Pay Benefits All subject to Deductible Plus Coinsurance (No Drug Card Benefit) $1,000, $2,000, $3,000 and $4,000 |
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Out-of-Pocket Maximum (2x Family) Plus Calendar Year Deductible |
Plan 1: $500, $1,000, $2,000 Plan 2: $1,000, $2,000, $4,000 |
Plan 1: $2,000, $4,000, $8,000 Plan 2: $2,500, $5,000, $10,000 |
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Coinsurance Percentage applies only to Covered Charges/Plus
Deductible |
Plan 1: 90% Plan 2: 80% |
Plan 1: 60% Plan 2: 50% |
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Emergency and Out-of-Area |
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Plan 1: 80% Plan 2: 70% |
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Physician’s Office – includes X-ray and Lab, CAT Scans, MRI Testing. Diabetes Supplies, Allergy Injections |
Plan 1: $25 Co-pay up to $200 per visit Plan 2: $35 Co-pay up to $200 per visit |
Deductible Plus Coinsurance Deductible Plus Coinsurance |
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Hospital Services Inpatient Room & Board Intensive Care, Immediate Care, or Cardiac Care Room & Board Emergency Room Non-Emergency Use of Emergency Room Diabetes Services In/outpatient PKU Formulas In/outpatient |
$150 Co-pay Plus average Semi-Private Deductible Plus Coinsurance 2 times average Semi-Private room rate/Deductible Plus
Coinsurance $50 Co-pay Deductible Plus Coinsurance 50% after Deductible Deductible Plus Coinsurance Deductible Plus Coinsurance |
$300 Co-pay Plus average Semi-Private Deductible Plus Coinsurance 2 times average Semi-Private room rate/Deductible Plus
Coinsurance $50 Co-pay Deductible Plus Coinsurance 50% after Deductible Deductible Plus Coinsurance Deductible Plus Coinsurance |
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Surgical Services Assistant Surgeon*, Anesthesia *Charges for an Assistant Physician are limited to 1/5 of the
Covered Charges allowed for the Surgery Physician – Inpatient |
Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance |
Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance |
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Adult Preventive Services Annual Maximum $200 Routine Mammography One per 12 month period Routine Pap Tests Prostate Cancer Screening One per 12 month period Children to Age 6 – Three visits per Calendar Year Immunizations Children Age 6 & Over – One visit per Calendar Year including
Immunizations |
Plan 1: $25 Co-pay Plan 2: $35 Co-pay Co-pay then 100% Co-pay then 100% Co-pay then 100% Co-pay then 100% 100% Co-pay then 100% |
Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance Deductible Plus Coinsurance 100% Deductible Plus Coinsurance |
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Hospice Care Inpatient Care Outpatient Care |
80% after Deductible Lifetime Maximum $10,000 80% after Deductible Lifetime Maximum $10,000 |
80% after Deductible Lifetime Maximum $10,000 80% after Deductible Lifetime Maximum $10,000 |
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Skilled Nursing Care Home Health Care Private Duty Nursing |
80% after Deductible Maximum $250 per Day Limit of 30 Days per Calendar Year 80% after Deductible Limit of 90 Days per Calendar Year 80% after Deductible Limit of 60 Eight-hour Shifts per Calendar Year |
80% after Deductible Maximum $250 per Day Limit of 30 Days per Calendar Year 80% after Deductible Limit of 90 Days per Calendar Year 80% after Deductible Limit of 60 Eight-hour Shifts per Calendar Year |
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Ambulance Service |
80% after Deductible Maximum per One-way Trip per Insured Person $1,000 for Ground Transportation $2,500 for Air Transportation |
80% after Deductible Maximum per One-way Trip per Insured Person $1,000 for Ground Transportation $2,500 for Air Transportation |
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Spinal Manipulation |
100% @ $30 per Visit Maximum 50 Visits per Calendar Year |
$30 per Visit Maximum 50 Visits per Calendar Year, subject to Deductible &
Coinsurance |
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Mental & Nervous Limitation 2-50 Employees $10,000 Lifetime Maximum 51-99 Employees $2,000,000 Lifetime Maximum |
70% Subject to Deductible Outpatient: 30 Visits per Calendar Year Inpatient: 30 days per Calendar Year Outpatient: 30 visits per Calendar Year |
50% Subject to Deductible Outpatient: 30 Visits per Calendar Year Inpatient: 30 days per Calendar Year Outpatient: 30 visits per Calendar Year |
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Supplemental Accident – Optional |
100% up to $300 per Accident |
100% up to $300 per Accident |
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Durable Medical Equipment |
20% Co-pay of Allowable Amount Plus Deductible and Coinsurance |
20% Co-pay of Allowable Amount Plus Deductible and Coinsurance |
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Well Baby Care Inpatient Maximum 4 Days Cesarean
Section Maximum 2 Days Vaginal
Delivery |
Deductible Plus Coinsurance Deductible Plus Coinsurance |
Deductible Plus Coinsurance Deductible Plus Coinsurance |
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Maternity Included for all groups insuring 5 or more Eligible
Employees |
Same as any other illness |
Same as any other illness |
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Reconstructive surgery after Mastectomy |
Same as any other illness |
Same as any other illness |
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Chemical Dependency |
Same as any other illness |
Same as any other illness |
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Temporomandibular Joint (TMJ) |
Same as any other illness |
Same as any other illness |
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Prescription Drug Card (Outpatient) Available to $500, $1,000, $2000 and $3,000 Deductible Plans |
Tier 1: Co-pay $2 (Generic Drugs) Tier 2:
Co-pay $15 (Cost-effective
brand drugs) or 20% of cost, whichever is greater (does not apply to calendar
year out-of-pocket of medical plan) Tier 3: Co-pay $30 (High cost brand drugs) or 30% of cost, whichever is greater (does not apply to
calendar year out-of-pocket of medical plan) Tier 4: Co-pay - Member pays the cost difference between generic drug and multiple-source brand drug regardless of either member or
physician request. (does not apply to calendar year out-of-pocket of medical plan) 30 day maximum supply 90 day supply by mail for 2 co-pays includes 20% or 30% cost share (does not apply to calendar year out-of-pocket of medical plan) |
No benefits payable for prescription drugs unless with prescription drug card used at a participating
pharmacy, except for the $250 deductible option. |
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Other Covered Charges (unless otherwise indicated) |
Deductible Plus Coinsurance |
Deductible Plus Coinsurance |
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Transplant Lifetime Maximum |
$250,000 |
$250,000 |
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Lifetime Maximum |
$2,000,000 |
$2,000,000 |
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This is only a
brief description of benefits available and will not be used to determine
benefits payable. The exact provisions
of the insurance coverage may be found in the Certificate issued to each
employee and may vary by state.
PRE-EXISTING CONDITION (MEDICAL)
There shall be no
benefits payable under the plan for expenses that result from care or treatment
of any condition or symptom for which a covered plan member received advice or consultation
or has taken any prescribed medication or has incurred any expenses due to the
condition during the six months preceding the date of enrollment. If the insured member (other than a late
enrollee) has been covered under the plan for 12 consecutive months, the
limitation will no longer apply.
However, the “Pre-existing Condition” exclusion time limitation will be
shortened by the aggregate period of time the employee or dependent, was
covered under Creditable Coverage if such coverage was continuous to a date not
more than 63 days prior to the enrollment date under the policy.