Human Resources

NDNU Medical Plans - Coverage Summary

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Plan Kaiser Health Plan (HMO) California Care Health Plan
(Blue Cross HMO H10)		 Prudent Buyer Health Plan
(Blue Cross PPO P5)
  In Network Out of Network
Maximum Lifetime Benefits Unlimited $5,000,000 per member $5,000,000 per member N/A
Deductible None $3,000 per member/year $3,000 per member/year $3,000 per member/year
Out-of-Network
Hospital Deductible		 N/A N/A N/A N/A
Hospital 100% 100% 80%, subject to deductible 60% of customary and reasonable
Physician Office Visits $15 co-pay $15 copay 60% of Usual & Customary charges after deductible $20 copay Plan covers 60%
Physicals & Immunizations $15 co-pay $15 co-pay Children under age 7:
100% of covered charges after $25 copay each Exam, 100% each Immunization
Person over age 7:
Preventive Care Centers only:
100% of covered charges, $25 copay each Exam (includes necessary immunizations)		 Children under age 7:
60% of customary & reasonable up to $20 each Exam
Person over age 7:
Not covered
Maximum Out-of-pocket Copay      
Individual $1,500 $3,000/ member per year $3,000/ member per year N/A
Two party $3,000 $3,000/member per year N/A N/A
Family $4,500 $3,000/member per year N/A N/A
Failure to Obtain Pre-certification N/A N/A $500 ded. waived for emergencies $500 ded. waived for emergencies
X-Ray & Lab 100% 60% of Usual & Customary charges after deductible 80% of covered charges 60% of customary & reasonable
Outpatient Surgery 100%/ $15 copay 60% of Usual & Customary charges after deductible 80% of covered charges 60% of customary & reasonable, $500 ded. for non-certification
Accident Benefits 100% N/A N/A N/A
Emergency Room
Life threatening		 $100 copay
(waived if admitted)

$100 copay, then 80%

80% of covered charges plus $100 (waived if admitted) 60% of customary & reasonable, $100 ded. (waived if admitted), subject to higher percentage rate for first 48 hrs

Maternity Care

(pre-natal and post-natal)

 $5.00 copay per visit 60% of Usual & Customary charges after deductible $20/visit (deductible waived N/A

Well-baby care/

immunizations

 $5.00 copay

60% of Usual & Customary charges after deductible

Limited to $20 per exam Immunizations are limited to $12 per immunization

$20/visit (deductible waived N/A
Pre-admission Testing 100% 100% 80% of covered charges plus 60% of customary & reasonable
2d Surgical Opinion 100% N/A 80% of covered charges plus 60% of customary & reasonable
Prescription Drug

$10 Generic/ $25 Brand per prescription

 $15 Generic/ $25 Brand per prescription $15 Generic/ $25 Brand per prescription N/A
Mental & Nervous   Inpatient & outpatient -
copay & max apply to Mental & Nervous, Alcohol & Drug Abuse combined
Outpatient $15 copay up to 20 visits per year Plan pays 60% 80% limited to $25/visit 60% limited to $25/visit
Inpatient $250 copay up to 45 days per year Plan pays 60% 80% limited to $25/visi 60% limited to $25/visit
Alcohol & Substance Abuse   80% limited to $25/visi 60% limited to $25/visit
Outpatient $15 per visit Plan pays 60%
Inpatient $250 per admit - detoxification only Plan pays 60%
Home Health 100%, $5 copay (when medically necessary) 100%, $5 copay, limited to three 2-hr visits per day 80% of covered charges, 100 visits/yr 60% of customary & reasonable, 100 visits/yr
Voluntary Sterilization 100% $150 copay women/$100 men 80% 60%
Physical Therapy

N/A

 60% benefit limited to $25/visit 80% 24 visits/ year 80% 24 visits/year
Chiropractic Treatment 10 visits/yr, $15 copay 60% benefit limited to $25/visit 80%, 24 visits/year 60%, $25 per visit, 24 visits/year
Skilled Nursing Care 100% - 100 days per calendar year 100%, 100 days/yr 80%, 100 days/yr 60%, 100 days/yr