PPO Base Plan Design

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LIMITED BENEFIT PLANS

Limited Benefit Plan

PPO Base Plan Design

Summary of Benefits

*BENEFIT CATEGORY*	*NETWORK*	*NON-NETWORK*
OUTPATIENT LAB AND X-RAY	Lab and x-ray services rendered by either a Contracting or Non-Contracting Provider on an outpatient basis will be paid at 100% of the first $350 of Allowed Amounts, per Covered Person, per Benefit Period. After the first $350 of Allowed Amounts, such services will be subject to either the Network or Non-Network Deductible and Coinsurance amounts required for other services. This benefit does not apply to services relating to accidental injury to teeth.
DEDUCTIBLE (per Benefit Period)
Individual Family	$1,000 $2,000	$2,000 $4,000
	The Deductibles for Network and Non-Network services are accumulated separately. At least two family members must contribute toward the family Deductible. The following do not count toward meeting the Deductible: Copayments; outpatient behavioral health and substance abuse (BH/SA); penalty for failure to prior authorize inpatient services; charges related to TMJ services; or difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.
DEDUCTIBLE CARRYOVER	Covered amounts applied towards the PHSIC Network Deductible in the last three (3) months of the Benefit Period will be credited to the next Benefit Period's Network Deductible. This carryover provision does not apply to the Non-Network Deductible or any prescription drug benefit.
COINSURANCE (after satisfaction of deductible)	80% of Allowed Amounts	50% of Allowed Amounts
OUT-OF-POCKET COINSURANCE MAXIMUM
Individual Family	$2,000 $4,000	$5,000 $10,000
Individual Family	$2,000 $4,000	$5,000 $10,000
(after satisfaction of deductible)	After the out-of-pocket coinsurance maximum has been reached, benefits will increase to 100% of the PHSIC Allowed Amounts for the remainder of the Benefit Period. The Covered Person will 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 coinsurance maximum: Copayments; Deductible; penalty for failure to prior authorize inpatient services; outpatient behavioral health and substance abuse (BH/SA); charges related to TMJ services; or difference between the actual billed charges of a Non-Contracting Provider and Allowed Amounts.
LIFETIME MAXIMUM	$1,000,000 The lifetime maximum will include benefits accumulated under another PHSIC Plan offered by the same employer prior to this coverage
DIAGNOSTIC TESTING except lab and x-ray	80%	50%
DIAGNOSTIC TESTING except lab and x-ray	This benefit does not apply to services relating to accidental injury to teeth.
INPATIENT BENEFITS* (Semi-Private Room, ICU, SNU, Hospice)	80%	50%
MATERNITY BENEFIT	80%	50%
OUTPATIENT SURGERY	80%	50%
PHYSICIAN OFFICE PROCEDURES AND INJECTIONS	80%	50%
IMMUNIZATIONS
Covered Persons up to 72 months of age;	100% (Deductible does not apply)	100%
Over 72 months with an Office Visit;	100% (Deductible does not apply)	50%
Over 72 months without an Office Visit	80%	50%
ANNUAL ROUTINE EYE EXAM	100%	50%
ANNUAL WELL WOMAN EXAM	100%	50%
INPATIENT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE*	80%	50%
INPATIENT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE*	Maximum benefit limted 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*	80%	50%
INPATIENT BIOLOGICALLY BASED MENTAL ILLNESS*	Maximum benefit limited 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 AND SUBSTANCE ABUSE	100% of first three visits; then 50% Deductible does not apply
OUPATIENT BIOLOGICALLY BASED MENTAL ILLNESS	80%	50%
OUPATIENT BIOLOGICALLY BASED MENTAL ILLNESS	Maximum benefit limited to forty-five (45) visits per Covered Person, per Benefit Period.
EMERGENCY ROOM SERVICES	$150 Emergency Room copayment	$300 Emergency Room copayment
	(waived if admitted)	(waived if admitted)
*There is no coverage for non Emergency Medical Conditions treated in a Hospital emergency room.*	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 Emer-gency Services will be covered at the Network Copayment, or the Network Deductible/ 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	80%	50%
*DURABLE MEDICAL EQUIPMENT AND SUPPLIES**	100% (Deductible does not apply)	50%
*DURABLE MEDICAL EQUIPMENT AND SUPPLIES**	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	80%	80%
DISPOSABLE MEDICAL SUPPLIES	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**	80%	50%
RECONSTRUCTIVE SURGERY FOLLOWING A MASTECTOMY**	80%	50%
RECONSTRUCTIVE SURGERY FOLLOWING A MASTECTOMY**	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	100% (Deductible does not apply)	50%
HOME HEALTH CARE	Maximum benefit limited to $2,500 of Allowed Amounts per Covered Person, per Benefit Period.
INTRAVENOUS (IV) AND INJECTABLE MEDICATIONS*	80%	50%
INTRAVENOUS (IV) AND INJECTABLE MEDICATIONS*	Prior Authorization required if given in the home.
OUTPATIENT HOSPICE SERVICES	100% (Deductible does not apply)	50%
TMJ (Deductible does not apply)	70%	70%
TMJ (Deductible does not apply)	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	80%	50%
OUTPATIENT SPEECH THERAPY	Maximum benefit limited to $1,500 of Allowed Amounts per Covered Person, per Benefit Period.
INPATIENT REHABILITATION *(Speech, Physical, Occupational)	80%	50%
INPATIENT REHABILITATION *(Speech, Physical, Occupational)	Maximum benefit limited to sixty (60) days per medical condition, per Covered Person, per Benefit Period.
OUTPATIENT REHABILITATION(Physical and Occupational)	80%	50%
OUTPATIENT REHABILITATION(Physical and Occupational)	Maximum benefit limited to $5,000 of Allowed Amounts per Covered Person, per Benefit Period.
SPINAL MANIPULATION SERVICES	80%	50%
SPINAL MANIPULATION SERVICES	Limited to a maximum benefit of $500 of Allowed Amounts per Covered Person, per Benefit Period.
ORTHOTICS AND PROSTHETICS* (Orthotic Shoes**)	80%	50%
ORAL SURGERY AND RELATED SERVICES**	80%	50%
ORAL SURGERY AND RELATED SERVICES**	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 benefit of $1,000 of Allowed Amounts, if provided within twelve (12) months from the date of the injury.
TRANSPLANT SERVICES*	80%	50% 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 Person 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	80%	50%
PRESCRIPTION DRUGS Certain medications require prior authorization. Preferred Options Network Preferred Choice Formulary (not applicable on 2-tier Rx plans)	34 Day Supply: $3 generic Copayment; 50% name brand coinsurance; 90 Day Supply: $10 generic Copayment; 50% name brand coinsurance	Member reimbursed Allowed Amount minus the Member's responsibility.
Please refer to your Pre-scription Drug Endorse-ment for complete plan provisions and limitations.	The benefits under this section will apply to Covered Prescriptions dispensed at a Contracting Mail Order or Retail Pharmacy who agrees in writing to the same terms and conditions that apply to the contractual agreement offered to any Contracting Mail Order Pharmacy.
*PHSIC recommends Prior Authorization of these services. 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. 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, Copayments, or Coinsurance unless otherwise stated. Please consult your Certificate for complete plan provisions, limitations, and exclusions. Please consult your Certificate for complete plan provisions and limitations BENEFIT PLAN underwritten by Preferred Health Systems Insurance Company.