Plan Name

HealthGuard POS In-Network

HealthGuard POS Out-of_Network

Web Site

www.hguard.com

www.hguard.com

Member Service Number

1-800-822-0350

Group Numbers

20703-061 - Salary

20703-051 - Hourly

1-800-822-0350

Group Numbers

20703-061 - Salary

20703-051 - Hourly

Individual Lifetime Maximum Benefits

None

$1 Million

Annual Deductible

          Individual

None

$150

          Family

None

$300

Coinsurance

None

20%

Annual Out-of-Pocket Maximum 

          Individual

None

$1,500 Plus Deductible

          Family

None

$3,000 Plus Deductible

Inpatient Hospital

100%

20% coinsurance

Physician Services: PCP Office Visit

$10 copay - also applies to specialist visit

20% coinsurance

Emergency Care: In-area Hospital

$25 copay

$25 copay

Outpatient X-Ray and Lab

Covered

20% coinsurance

Durable Medical Equipment

100%

80% after deductible

Retail Prescription Coverage

          Generic

15% (Represented)

20% (Salaried)

15% (Represented)

20% (Salaried)

          Brand Name

25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)

25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)

Mail-Order Prescription Coverage

          Generic

10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary

(Represented)

10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)

10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary

(Represented)

10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)

          Brand Name

See Above

See Above

Diabetic Benefits

          Insulin

100%

100%

          Chem.    Strips/Lancets

100%

100%

          Home Health Care

100%

80% after deductible

Mental Health 

          Inpatient 

100% up to 30 days per year

80% after deductible up to 30 days per year

          Outpatient

$15 copay up to 50 visits per year 

80% after deductible up to 50 visits per year

Substance Abuse

          Inpatient

100% - 90 day lifetime maximum

80% - 90 day lifetime maximum

          Outpatient

$15 copay -120 day lifetime maximum

80% - 120 day lifetime maximum

Vision Care

          Routine Eye Exam

Not Covered

Not Covered

          Eyeglasses and Contact Lenses

Not Covered

Not Covered

Hearing Care

          Exam

$10 copay every 3yrs

80 % after deductible

          Hearing Aids

100% up to $1,000 every 3yrs.

80% after deductible up to $1,000 every 3yrs.

Dental Care

          Basic Services

Not Covered

Not Covered

          Major Services

Not Covered

Not Covered

          Preventive Services

Not Covered

Not Covered

Wellness Benefits

100% after $10 copay

Not Covered