|
"Bold" print
identifies plan changes effective 1/1/2003
|
|
Plan
Name
|
Burns
Harbor PHP In-Network
|
Burns
Harbor PHP Out-of-Network
|
Humana
Medical
|
|
Web Site
|
www.anthem-inc.com
|
www.anthem-inc.com
|
www.humana.com
|
|
Member
Service Number
|
1-866-528-2658
|
1-866-528-2658
|
1-800-4Humana
1-800-448-6262
Pre-Enrollee
Number: 1-800-393-6765
Group
No. 13175
|
|
Individual
Lifetime Maximum Benefits
|
$1
Million combined in/out-of-network
|
None
|
$1
Million
|
|
Annual
Deductible
|
|
|
|
|
Individual
|
None
|
None
|
None
|
|
Family
|
None
|
None
|
None
|
|
Coinsurance
|
None
|
25%
|
None
|
|
Annual
Out-of-Pocket Maximum
|
|
|
|
|
Individual
|
None
|
$2,000
|
$1,500
(maximum copay)
|
|
Family
|
None
|
$4,000
|
$3,000
(maximum copay)
|
|
Inpatient
Hospital
|
100%
|
75%
UCR
|
100%
covered |
|
Physician
Services: PCP Office Visit
|
$10
copay
|
75%
UCR less $10 copay
|
$15
copay per visit
|
|
Emergency
Care: In-area Hospital
|
100% -
less $25 copay (Waived if admitted)
|
75%
UCR less $25 copay
|
$50
copay (Waived of admitted) |
|
Outpatient
X-Ray and Lab
|
100%
|
75%
UCR
|
100%
covered |
|
Durable
Medical Equipment
|
100%
|
100%
|
100%
covered
|
|
Retail
Prescription Coverage
|
|
|
|
|
Generic
|
15%
|
15%
|
$10
copay for 30-day supply
|
|
Brand Name
|
25%
if generic unavailable; 30% if generic available and medically
necessary
|
25%
if generic unavailable; 30% if generic available and medically
necessary
|
$20
copay for 30-day supply of Preferred Brand Names; $35 copay for
30-day supply of Non-Preferred Brand Names |
|
Mail-Order
Prescription Coverage
|
|
|
|
|
Generic
|
10% generic; 20% brand if generic unavailable; 25% if generic
available and medically necessary
|
10%
generic; 20% brand if generic unavailable; 25% if generic available
and medically necessary |
$30 copay
for 90-day supply
|
|
Brand Name
|
See Above
|
See
Above
|
$60 copay
for 90-day supply of Preferred Brand Names; $105 copay for 90 day
supply of Non-Preferred Brand Names |
|
Diabetic
Benefits
|
|
|
|
|
Insulin
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
|
Subject
to prescription drug copay |
|
Chem. Strips/Lancets
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
|
Subject
to prescription drug copay |
|
Home Health Care
|
100%
up to 100 visits per calendar year
|
Not Covered
|
100%
covered
|
|
Mental
Health
|
|
|
|
|
Inpatient
|
100%
up to 60 days per calendar year (OP days count toward maximum)*
|
Not Covered
|
100%
covered for 30 days per calendar year
|
|
Outpatient
|
100%
up to 80 days per calendar year (IP days count towards maximum
|
Not Covered
|
$20
copay for up to 20 visits per calendar year
|
|
Substance Abuse
|
|
|
|
|
Inpatient
|
100%
up to 60 days per lifetime (combined with OP days)*
|
Not Covered
|
"Detoxification 100% covered Rehabilitation 100% covered up 30
days per calendar year"
|
|
Outpatient
|
100%
up to 60 days per lifetime (combined with IP days)*
|
Not Covered
|
"Detoxification 100% covered Rehabilitation $20 copay per visit
20 visits per calendar year"
|
|
Vision
Care
|
|
|
|
|
Routine Eye Exam |
Not Covered
|
Not Covered
|
100%
Covered
|
Eyeglasses and Contact Lenses
|
$10
copay for screening exam
|
Not Covered
|
$75
allowance every two years
|
|
Hearing
Care |
|
|
|
|
Exam |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
|
Not Covered
|
100%
covered
|
|
Hearing Aids |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
|
Not Covered
|
Not Covered
|
|
Dental
Care |
|
|
|
|
Basic Services |
Not Covered
|
Not Covered
|
Not Covered
|
|
Major Services |
Not Covered
|
Not Covered
|
Not Covered
|
|
Preventive Services |
Not Covered
|
Not Covered
|
Not Covered
|
|
Wellness
Benefits |
$10
copay
|
No
|
$15
copay for annual physical, well child care annual OB/GYN prostate
screening Mammography 100% Covered
|