|
Plan Name |
Sound
Harbor Elite |
|
PCY = per calendar year |
|
Annual Deductible
Per individual PCY;
the maximum deductible
per family equals 3 times the individual amount; the deductible applies to all
expenses unless otherwise noted |
$1,000 |
|
Lifetime Maximum |
$1 million per individual |
Annual Coinsurance Maximum
Per
individual PCY;
the maximum coinsurance per family
equals 3 times the individual amount; once the coinsurance is met,
providers are
covered in full |
$5,000 |
Preventive Care
No deductible
Annual routine physical exam, well baby care (to 24 months of age),
annual routine eye exam and smoking cessation |
70%
$250 maximum per calendar year |
Professional
Services
Office, home, naturopath or
urgent care
visits |
70% |
|
Other Outpatient Professional Services |
70% |
|
Outpatient Lab & X-Ray |
70% |
Mammography & Prostate Cancer
Screening - Routine
No deductible |
70% |
Mammography & Prostate Cancer
Screening - Diagnostic
Paid after deductible |
70% |
|
 |
|
Plan Name |
Sound
Harbor Elite |
| PCY
= per calendar year |
|
|
Facility/Hospital Care - Inpatient |
70% after $250
copay per day
3 copay maximum ($750) per admission |
|
Facility/Hospital Care - Outpatient |
70% after $100
copay |
|
Emergency Room & Supplies |
70% after $100
copay per visit (copay waived if admitted) |
Acupuncture Services
|
70%
12 treatments maximum PCY |
Ambulance
|
70%
$5,000 maximum benefit PCY |
Home Health Care
|
70%
130 visits limit PCY |
|
Hospice
|
70%
6 month maximum PCY |
|
Maternity |
Covered same as
Professional and Facility/Hospital services shown above |
|
Medical Equipment & Supplies
|
70%
$2,500 maximum benefit PCY |
| Mental
Health - Inpatient |
Covered same as
Facility/Hospital - Inpatient service shown above
10 days limit PCY |
| Mental
Health - Outpatient |
70%
12 visits limit PCY |
|
|
|
Plan Name |
Sound
Harbor Elite |
| PCY
= per calendar year |
|
| Nutritional
Guidance |
70%
$400 maximum benefit PCY |
Rehabilitation
Outpatient only (inpatient
rehabilitation not covered)
Including physical, speech, massage and occupational therapy |
70%
$1,000 maximum benefit PCY |
Prescription Drugs
$2,000
maximum benefit PCY;
Prescriptions limited to 30-day supply per prescription at a
participating retail pharmacy |
Tier 1 (Generic): 100% after $10
copay (no deductible)
Tier 2 (Preferred
Brand-Name): 50% with $45 minimum copay
Tier 3 (Non-Preferred
Brand-Name): 50% with $45 minimum copay
Tiers 2 and 3 are subject to a $200 deductible PCY |
Skilled Nursing Facility
in lieu of hospitalization |
70% |
|
Spinal and Extremity Manipulations
|
70%
12 manipulations maximum PCY |
Organ
Transplants
12-month waiting period
$100,000 lifetime maximum |
70% |
| Pre-Existing
Conditions |
A
pre-existing condition is one for which there has been diagnosis,
treatment (including the use of prescribed drugs), or medical advice
within the six month period prior to the effective date of coverage
or a condition for which symptoms existed within the six month
period prior to the date of coverage and for which a prudent person
would have ordinarily sought treatment.
Pre-existing conditions
will not be covered until a member has been continuously enrolled
under this plan for 9 (nine) months. In some cases, KPS Health Plans
will apply credit for pre-existing conditions if the person
enrolling has been covered by a prior group or individual health
benefit plan that is considered "creditable" coverage
(i.e., a plan that had benefits as good or better than this plan),
at any time during the 63 (sixty-three) day period immediately
preceding the receipt date of the application. |
