TABLE OF CONTENTS
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.

 

  • Medical Expenses – Option I (not available to Retirees eligible to Medicare)

 

$350.00

Individual

$700.00

Family

 

  • Medical Expenses – Option II

$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

 

  • Home Health Care

100%

  • Hospice Care

100%

Inpatient and Outpatient Hospital Care

 

  • Wyoming Network Hospitals

85%

  • Wyoming Non-Network Hospitals

80%

  • Network Hospitals outside of Wyoming

80%

  • Non-network Hospitals outside of Wyoming

60%

Physician charges for Surgery and Hospital Care

 

  • Wyoming Network Physicians

85%

  • Wyoming Non-Network Physicians

80%

  • Network Physicians outside of Wyoming

80%

  • Non-network Physicians outside of Wyoming

60%

Office visits including Wellness Care

 

  • Wyoming Network Physicians

85%

  • Wyoming Non-Network Physicians

80%

  • Network Physicians outside of Wyoming

80%

  • Non-network Physicians outside of Wyoming

60%

 

 

Emergency Room Treatment

  • Emergency services

80%

  • Non-emergency services

 

- 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

  • Individual

$15,000.00

  • Family

$30,000.00

CALENDAR YEAR BREAKPOINT – ALL OTHER PROVIDERS

  • Individual

$10,000.00

  • Family

$20,000.00

BENEFIT MAXIMUMS

  • Lifetime inpatient mental/nervous

60 days

  • Lifetime inpatient substance abuse

2 series of treatments

- First series of treatment of substance abuse

20 days

- Second series of treatment of substance abuse

10 days

  • Calendar year outpatient mental/nervous and substance abuse

50 visits

  • Lifetime outpatient mental/nervous and substance abuse maximum

420 visits

  • Calendar year home health care visits

100

  • Calendar year skilled nursing facility days

180

  • Hospice inpatient days

180

  • Hospice bereavement

$300.00

  • Specified therapies per visit (covered amount)

- Manual manipulation of the musculo-skeletal system

$37.50

- Other specified therapies

$50.00

  • Calendar year specified therapies

30 visits

  • Air ambulance per trip

$5,000.00

  • Organ transplant maximums

- 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

  • Maximum Benefit for ALL covered expenses (per covered person)

$2,000,000.00

Summary of Prescription Drug Benefits

Percentage Payable

  • Generic Drugs

100% after $10.00 co-pay

  • Brand Name Drugs

 

- 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.

 


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