SUMMARY OF MEDICAL BENEFITS

CALENDAR YEAR DEDUCTABLE

The calendar year deductible applies to all covered expenses except those payable at 100% and wellness services.

       Individual

$350.00

       Family

$700.00

       Individual

$750.00

       Family

$1,500.00

  • Medical Expenses - Option III
  

       Individual

$2500.00
   

MEDICAL MANAGEMENT PENALTY COINSURANCE FOR INPATIENT HOSPITAL EXPENSES

60%

 MEDICAL MANAGEMENT PENALTY FOR OUTPATIENT SURGERY

$250.00

PERCENTAGE PAYABLE FOR COVERED SERVICES

  • COST-EFFECTIVE SERVICES

       Home Health Care

100%

       Hospice Care

100%

       Wyoming Network Hospitals

85%

       Wyoming Non-Network Hospitals

80%

       Network Hospitals outside of Wyoming

80%

       Non-Network Hospitals outside of Wyoming

60%

       Wyoming Network Physicians

85%

       Wyoming Non-Network Physicians

80%

       Network Physicians outside of Wyoming

80%

       Non-Network Physicians outside of Wyoming

60%

       Wyoming Network Physicians

85%

       Wyoming Non-Network Physicians

80%

       Network Physicians outside of Wyoming

80%

       Non-Network Physicians outside of Wyoming

60%

       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

  • 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
  • Lifetime organ transplant

    $1,000,000.00

       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