BENEFIT CATEGORY

NETWORK

NON-NETWORK

DEDUCTIBLE
(per Benefit Period)
Individual
(Single Coverage only)
Family

Includes medical benefits

$4,000  

$8,000

$8,000

 $16,000

The Deductibles for Network and Non-Network services are accumulated separately.
All services are subject to Deductible unless otherwise indicated.
The following do not count toward meeting the Deductible: penalty for failure to prior authorize inpatient services; or difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.

COINSURANCE
(after satisfaction of Deductible)

50%
of Allowed Amounts

50%
of Allowed Amounts

OUT-OF-POCKET MAXIMUM
Individual
(Single Coverage only)
Family

Includes Deductible and Coinsurance for medical  benefits

$5,000

 $10,000

$10,000

$20,000

After the out-of-pocket maximum has been reached, benefits will increase to 100% of the Allowed Amounts for the remainder of the Benefit Period.  The Covered Person will still be responsible for the difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.  The following do not count towards meeting the out-of-pocket maximum: penalty for failure to prior authorize inpatient services; or difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.

LIFETIME MAXIMUM

$1,000,000

PREVENTIVE SERVICES

100% (not subject to Deductible)

50% (Deductible applies)

Coverage limited to: routine physicals for Covered Persons up to 72 months of age, an annual eye exam, an annual routine physical for Covered Persons over 72 months of age, an annual well woman exam (includes pap and mammogram), PSA, flu shot, and pneumonia shot.

OUTPATIENT LAB AND
X-RAY SERVICES

 

50% (Deductible applies)

50% (Deductible applies)

This benefit does not apply to services relating to accidental injury to teeth.  PHSIC requires Prior Authorization of PET scans.

INPATIENT BENEFITS*
(Semi-Private Room, ICU, SNU, Hospice)

50% (Deductible applies)

50% (Deductible applies)

MATERNITY BENEFIT

 50% (Deductible applies)

50% (Deductible applies)

OUTPATIENT SURGERY

 50% (Deductible applies)

50% (Deductible applies)

PHYSICIAN OFFICE PROCEDURES AND INJECTIONS

 50% (Deductible applies)

50% (Deductible applies) 

IMMUNIZATIONS

Covered Persons up to
72 months of age 

100% (not subject to Deductible)

100% (not subject to Deductible)

Covered Persons over
72 months of age

50% (Deductible applies)

50% (Deductible applies)

INPATIENT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE*

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to thirty (30) days per Covered Person, per Benefit Period.  Each partial day session will count as one-half inpatient day toward the thirty (30) day benefit. 

INPATIENT BIOLOGICALLY BASED MENTAL ILLNESS* 

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limit to forty-five (45) days per Covered Person, per Benefit Period.  Each partial day session will count as one-half inpatient day toward the forty-five (45) day benefit. 

OUTPATIENT BEHAVIORAL HEALTH

 50% (Deductible applies)

50% (Deductible applies)

OUTPATIENT SUBSTANCE ABUSE 

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to $2,500 of Allowed Amounts per Covered Person, per Benefit Period and Maximum benefit limited to $7,500 of Allowed Amounts per Covered Person, per lifetime.

OUPATIENT BIOLOGICALLY BASED MENTAL ILLNESS

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to forty-five (45) visits per Covered Person, per Benefit Period.

EMERGENCY ROOM SERVICES


 

There is no coverage for non Emergency Medical Conditions  treated in a Hospital emergency room.

 50% (Deductible applies)

50% (Deductible applies)

An observation stay of twenty-four (24) hours or longer will be treated as an inpatient admission at the applicable Network or Non-Network level. 

Non-Network Emergency Services will be covered at the Network Deductible and Coinsurance level (if admitted), if PHSIC is notified within twenty-four (24) hours or the next business day.  The Covered Person will be responsible for the difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.

AMBULANCE

 50% (Deductible applies)

50% (Deductible applies)

DURABLE MEDICAL EQUIPMENT* AND SUPPLIES

 

 50% (Deductible applies)

50% (Deductible applies)

Durable Medical Equipment and supplies are limited to a maximum benefit of $2,500 of Allowed Amounts per Covered Person, per Benefit Period.

DISPOSABLE MEDICAL SUPPLIES

 50% (Deductible applies)

 50% (Deductible applies)

Coverage is limited to a maximum benefit of $500 of Allowed Amounts per Covered Person, per Benefit Period:
- Ostomy (appliance pouches, skin care agents, support belts)
- Open wound (gauze pads, wound packing strips, ABD pads)
- Venous access catheter (alcohol pads, benzoin, dressings)
- Urinary supplies (catheter and bag supplies)
- Tracheostomy supplies
- Compression stockings
- Inhaler supplies (aero chamber masks, spacers, peak flow meters)

DIABETIC EQUIPMENT*
AND SUPPLIES

50% (Deductible applies)

50% (Deductible applies)

RECONSTRUCTIVE SURGERY**  FOLLOWING A MASTECTOMY

 50% (Deductible applies)

50% (Deductible applies)

Coverage will be provided in a manner determined in consultation with the treating Physician and the Member for reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce symmetrical appearance; prostheses and physical complications during all stages of the mastectomy, including lymphedema.

HOME HEALTH CARE

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to $2,500 of Allowed Amounts per Covered Person, per Benefit Period.

INTRAVENOUS (IV) AND  INJECTABLE MEDICATIONS*

 50% (Deductible applies)

50% (Deductible applies)

Prior Authorization required if given in the home.

OUTPATIENT HOSPICE SERVICES

 50% (Deductible applies)

50% (Deductible applies)

TMJ

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to $1,000 of Allowed Amounts per Covered Person, per Benefit Period; $5,000 of Allowed Amounts per lifetime.

OUTPATIENT SPEECH THERAPY 

50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to $1,500 of Allowed Amounts per Covered Person, per Benefit Period.

INPATIENT REHABILITATION*
(Speech, Physical, Occupational)

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to sixty (60) days per medical condition, per Covered Person, per Benefit Period.

OUTPATIENT REHABILITATION
(Physical and Occupational)

 50% (Deductible applies)

50% (Deductible applies)

Maximum benefit limited to $5,000 of Allowed Amounts per Covered Person, per Benefit Period.

SPINAL MANIPULATION SERVICES

 50% (Deductible applies)

50% (Deductible applies)

Limited to a maximum benefit of $500 of Allowed Amounts per Covered Person, per Benefit Period.

ORTHOTICS AND PROSTHETICS**
(orthotic shoes**)

 50% (Deductible applies)

50% (Deductible applies)

ORAL SURGERY AND RELATED  SERVICES**

50% (Deductible applies

50% (Deductible applies)

Services for accidental injury (not from biting or chewing) to sound, natural teeth will be covered at the Network Deductible and Coinsurance level up to a maximum of $1,000 of Allowed Amounts, if provided within twelve (12) months from the date of the injury.

TRANSPLANT SERVICES*

50% (Deductible applies)

50% (Deductible applies)

Subject to lifetime maximums

All Organ Transplants must be Prior Authorized with PHSIC prior to the transplant.  This applies to both Network and Non-Network benefits. 

Network transplant limitations will be determined at time of Prior Authorization.

Covered Persons are entitled to receive benefits for human organ and tissue transplant services through Contracting Providers.

Kidney:  $100,000
Kidney/Pancreas;  Heart; Heart/Lung; Autolgous Bone Marrow: $150,000
Allogenic Bone Marrow; Intestine; Liver; Lung (single or double): $200,000

ALL OTHER COVERED SERVICES

 50% (Deductible applies)

50% (Deductible applies)

50% Deductible Applies
Certain medications require prior authorizations

*The Covered Person or provider is responsible for obtaining Prior Authorization from PHSIC. If inpatient services are not Prior Authorized, a $500 penalty will apply.

**PHSIC recommends Prior Authorization of these services.

The Prior Authorization List is subject to change.  An up-to-date Prior Authorization List can be found at www.phsystems.com or by calling Member Services at 316-609-2390 or 1-800-660-8114 (outside Wichita).

All benefits and the Coinsurance percentage are based on Allowed Amounts.  All benefits are subject to Deductible and/or coinsurance unless otherwise stated.

 Limitations and Exclusions:
-  Any services which are not Medically Necessary. 
-  Experimental and investigational treatment unless otherwise described in Certificate. 
-  Surgical treatment and all services related to such treatment of obesity (including morbid obesity) and weight reduction. Any medical services rendered in conjunction with prescription drug therapy for weight control.  Such services include prescriptions, hospitalizations, laboratory and x-ray services, and Physician office visits.

-  Cosmetic, health, and beauty aids
-  Services for injuries or diseases related to employment to the extent you are covered or are required to be covered by workers’ compensation law and services resulting from injuries related to a motor vehicle accident and should be or are covered under automobile insurance.
-  Duplication of benefits provided by Federal, State or local laws such as Medicare, CHAMPUS, Tricare, and services in any veteran’s facility. 
-  Items not strictly for the purpose of treating a medical condition including, but not limited to, shower chairs, breast pumps, and laboratory and x-ray services, and Physician office visits.
-  Items not strictly for the purpose of treating a medical condition including, but not limited to, shower chairs, breast pumps, and prenatal cradles.

Please consult your Certificate for complete plan provisions, limitations, and exclusions.