Health Plan Benefits

Summary of Benefits for the High Option of the Rural Carrier Benefit Plan - 2010

Please do not rely on this chart alone.  All benefits are subject to the definitions, limitations and exclusions in the Official Plan Brochure. On this page, we summarize specific expenses we cover. For more detail, refer to the Official Plan Brochure. 

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover of your enrollment form.

Below, an asterisk (*) means the item is subject to the $350 PPO / $400 Non-PPO calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a non-PPO physician or other health care professional. 

Medical Services Provided by Physicians

Topic	You Pay
High Option Benefit	PPO	Non-PPO
Diagnostic and treatment services provided in the office	$20/office visit; $30/specialist visit	25% of our allowance and any difference between our allowance and the billed amount*
Surgery	10% of our allowance (no deductible)	20% of our allowance and any difference between our allowance and the billed amount

Services Provided by a Hospital

Topic	You Pay
High Option Benefit	PPO	Non-PPO
Inpatient	$100 copayment per admission (waived for maternity stay)	$300 copayment per admission; 20% of room and board and other charges
Outpatient	15% of our allowance*	30% of our allowance* and any difference between our allowance and the billed amount

Emergency Benefits

High Option Benefit	You Pay
Accidental injury	Nothing for emergency room visit and first physician office visit
Medical emergency	Regular benefits

Mental Health & Substance Abuse Treatment

Topic	You Pay
High Option Benefit	PPO	Non-PPO
Inpatient	$100 copayment per admission	$300 copayment per admission; 20% for room and board; 20% of other charges
Outpatient	15% of our allowance* (no deductible on physician visits)	Nothing

Prescription Drugs

Topic	You Pay
High Option Benefits	Generic	Preferred Brand Name	Non-Preferred Brand Name
Network and Non-Network Pharmacy	30% of cost*	30% of cost*	30% of cost*
Mail order pharmacy (up to a 90 day supply)	$10	$28	$45
Mail order pharmacy with Medicare Part B (up to a 90 day supply)	$10	$18	$35

Dental Care

High Option Benefit	You Pay
Dental care	Any difference between our scheduled allowance and the billed amount

Protection against Catastrophic Costs

Topic	You Pay
High Option Benefit	PPO	Non-PPO
Protection against catastrophic costs (out-of-pocket maximum) Note: Benefit maximums apply and some costs do not count toward this protection	Nothing after $3,500/person or $4,000/family per calendar year	Nothing after $4,000/person or $4,500/family per calendar year

Special Features

The Plan offers the following Special features:

• Flexible benefits option
• Cancer treatment benefit
• Kidney dialysis benefit
• 24 hour nurse line
• Travel assistance program
• Routine eye exam benefit
• Healthy maternity program
• Disease management programs
• Lab One program
• Centers of excellence