|
Benefits |
KPS Health Plans
Sound Harbor Classic |
| |
Network Provider |
Annual Deductible
Per
calendar year |
$500 per person
$1,500 per family |
|
Lifetime Maximum |
$2,000,000 per person |
Annual Out-of-Pocket Maximum
Deductible not included; after the
out-of-pocket maximum is satisfied, network providers are covered at
100% |
$5,000 per person, per calendar year
$15,000 per family, per calendar year |
Hospital
Inpatient/Outpatient
Emergency Room |
80% |
|
Outpatient Professional |
80% |
|
Maternity |
80% |
|
Sterilization |
80% |
Preventive Care
Routine exam, immunizations, well-baby care (includes
professional services for smoking cessation and routine eye exam) |
100% to $250
maximum per calendar year
(not subject to deductible) |
|
Routine Vision Exams |
Annual eye exam
included in
Preventive Care benefit |
|
Vision Hardware |
80% of $250 ($200
maximum benefit)
every 2 calendar years |
Ambulance
Air and ground combined |
80% to $5,000
maximum per calendar year |
Home Health
Limited
to 130 visits per calendar year |
80% |
Hospice
Limited
to 6 months per calendar year |
80% |
Skilled Nursing Facility
In lieu of
hospitalization |
80% |
|
Durable Medical Equipment (DME) |
80% to $2,500
maximum per calendar year |
Organ Transplant
12-month waiting period |
80% to $100,000
lifetime maximum |
|
Rehabilitation - Outpatient |
80% to $1,000
maximum per calendar year |
|
Rehabilitation - Inpatient |
Not covered |
|
Mental Health (inpatient/outpatient) |
Not covered |
|
Chemical Dependency (inpatient/outpatient) |
Not covered |
Prescription Drugs
$2,000
maximum benefit per calendar year |
After the annual deductible is satisfied,
the
member pays:
Tier 1 = $10 (generic drugs)
Tier 2 = $30 (preferred brand name drugs)
Tier 3 = 50% (non-preferred brand name drugs) |
|
Nutritional Guidance |
80% to $400 maximum
per calendar year |
Spinal Manipulations
Limited to
12 manipulations per person, per calendar year |
80% |
Acupuncture
Limited to
12 needle treatments per person, per calendar year |
80% |
|
Naturopathy |
80% |
|
Physical/Massage Therapy |
Covered under
Outpatient Rehabilitation benefit |
|
Dietitians/Nutritionists |
80% |
|
Smoking Cessation |
Covered under
Preventive Care and
Prescription Drug benefits |
