APPENDIX
B |
||
EGI
Major Medical Plan Features |
EGI Benefits and Coverage
Summary
of Medical Benefits |
|
CALENDAR
YEAR DEDUCTIBLE
|
|
The calendar year deductible applies to all
covered expenses except those payable at 100% and wellness services. |
|
|
$350.00 |
Individual |
$700.00 |
Family |
|
|
$750.00 |
Individual |
$1,500.00 |
Family |
|
MEDICAL MANAGEMENT PENALTY COINSURANCE FOR
INPATIENT HOSPITAL EXPENSES |
60% |
MEDICAL MANAGEMENT PENATY FOR OUTPATIENT SURGERY |
$250.00 |
|
|
PERCENTAGE
PAYABLE FOR COVERED SERVICES
|
|
Cost-Effective Services |
|
|
100% |
|
100% |
Inpatient and Outpatient Hospital Care |
|
|
85% |
|
80% |
|
80% |
|
60% |
Physician charges for Surgery and Hospital Care |
|
|
85% |
|
80% |
|
80% |
|
60% |
Office visits including Wellness Care |
|
|
85% |
|
80% |
|
80% |
|
60% |
|
|
Emergency Room Treatment |
|
|
80% |
|
|
- If surgery is
not performed |
80% |
- If surgery is
performed |
|
¬
Wyoming Network Hospitals |
85% |
¬
Wyoming Network Physicians |
85% |
¬
Wyoming Non-Network Hospitals |
80% |
¬
Wyoming Non-Network Physicians |
80% |
¬
Network Hospitals outside of Wyoming |
80% |
¬
Network Physicians outside of Wyoming |
80% |
¬
Non-network Hospitals outside of Wyoming |
60% |
¬
Non-network Physicians outside of Wyoming |
60% |
Other Covered Expenses |
80% |
CALENDAR YEAR BREAKPOINT – NON-NETWORK
PROVIDERS OUTSIDE OF WYOMING |
|
|
$15,000.00 |
|
$30,000.00 |
CALENDAR YEAR BREAKPOINT – ALL OTHER PROVIDERS |
|
|
$10,000.00 |
|
$20,000.00 |
BENEFIT MAXIMUMS |
|
|
60
days |
|
2
series of treatments |
- First series of
treatment of substance abuse |
20
days |
- Second series of
treatment of substance abuse |
10
days |
|
50
visits |
|
420
visits |
|
100 |
|
180 |
|
180 |
|
$300.00 |
|
|
- Manual
manipulation of the musculo-skeletal system |
$37.50 |
- Other specified
therapies |
$50.00 |
|
30
visits |
|
$5,000.00 |
|
|
- Organ and tissue
procurement per transplant benefit period |
$25,000.00 |
- Transportation,
lodging and meals per transplant benefit period |
$10,000.00 |
¬
Covered lodging and meals per day |
$200.00 |
- Private duty
nursing care per transplant benefit period |
$10,000.00 |
|
$2,000,000.00 |
Summary of Prescription Drug Benefits |
|
Percentage Payable |
|
|
100%
after $10.00 co-pay |
|
|
- Preferred Drugs
and Neutral Drugs |
100%
after $20.00 co-pay |
- Non-Preferred
Drugs |
100%
after $40.00 co-pay |
Prescription drug co-payments do not count
toward the health plan deductible or calendar year breakpoints. |
Source:
The Wyoming State Employees’ and Officials’ Group Insurance Plan
Employee Benefit Booklet.