Trees

NDNU Medical Plans - Coverage Summary

Plan
In Network Out of Network
Maximum Lifetime Benefits Unlimited None None Unlimited Unlimited
Deductible None Individual:
$1,500/yrFamily:
$3,000/yr
None $250 per member$750 per family $750 per member$2,250 per family
Out-of-Network
Hospital Deductible
N/A N/A N/A $500 per admission
(waived for emergency admission)
Hospital $250 per admission 10% coinsurance after deductible $250 copay per admission 20% coinsurance 40% coinsurance
Physician Office Visits $15 copay per visit 10% coinsurance per visit $15 copay per visit $20 copay per visit (deductible waived) 40% coinsurance
Physicals & Immunizations No copay No copay No copay No copay (deductible waived) 40% coinsurance
Maximum Out-of-pocket Copay
Individual $1,500 per member/yr $3,000/yr $2,000 per member/yr $3,000 per member/yr $6,000 per member/yr
Two party $1,500 per member/yr $6,000/yr N/A N/A N/A
Family $3,000 per family/yr $6,000/ yr $4,000 per family/yr $6,000 per family/yr $12,000 per family/yr
X-Ray & Lab No copay
(most X-rays and lab tests)
10% coinsurance after deductible (most X-rays and lab tests) $100 per advanced imaging testAll other tests: No copay 20% coinsurance (subject to utiliziation review) 40% coinsurance up to $800 per procedure for advanced imaging (subject to utilization review)
Outpatient Surgery $15 copay per procedure 10% coinsurance per procedure after deductible $125 per admission 20% coinsurance 40% coinsurance
Emergency Room
Life threatening
$100 copay per visit 10% coinsurance per visit after deductible $150 copay per visit (waived if admitted) $100 deductible, then 20% coinsurance
($100 deductible waived if admitted)
$100 deductible, then 20% coinsurance
($100 deductible waived if admitted)
Maternity Care(pre-natal and post-natal) No copay Pre-natal:
No copay
Post-natal:
10% coinsurance per visit
$15 copay per visit $20 copay per visit (deductible waived) 40% coinsurance
Well-baby care/immunizations No copay No copay No copay $20 copay per visit (deductible waived) 40% coinsurance
Prescription Drug Retails and mail-orderGeneric:
$10 copay for 30-day after deductible,
$20 copay for 31- to 60-day after deductible,
$30 copay for 61- to 100-day after deductible, (not available for mail-order)Brand:
$25 copay for 30-day after deductible,
$50 copay for 31- to 60-day after deductible,
$75 copay for 61- to 100-day after deductible, (not available for mail-order)
Retails and mail-orderGeneric:
$10 copay for 30-day after deductible
$20 copay for 31- to 60-day after deductible
$30 copay for 61- to 100-day after deductible (not available for mail-order)Brand:
$30 copay for 30-day after deductible
$60 copay for 31- to 60-day after deductible
$90 copay for 61- to 100-day after deductible (not available for mail-order)
Retail up to 30-day supply:
Generic: $15
Brand: $30
Non-formulary: $50Mail order up to 90-day supply:
Generic: $15
Brand: $60
Non-formulary: $100
Retail up to 30-day supply:
Generic: $15
Brand: $25
Non-formulary: $45Mail order up to 90-day supply:
Generic: $15
Brand: $50
Non-formulary: $90
Mental & Nervous Inpatient & outpatient -
copay & max apply to Mental & Nervous, Alcohol & Drug Abuse combined
Outpatient $15 copay per individual visit$7 copay per group treatment visit 10% coinsurance per individual/ group visit after deductible $15 copay per visit (pre-authorization required) $20 copay per visit, deductible waived
(subject to pre-service review)
40% coinsurance per visit
(subject to pre-service review)
Inpatient $250 copay per admission 10% coinsurance per admission after deductible $250 copay per admission
(pre-authorization required)
20% coinsurance 40% coinsurance
Alcohol & Substance Abuse Inpatient & outpatient -
copay & max apply to Mental & Nervous, Alcohol & Drug Abuse combined
Outpatient $15 copay per individual visit$5 copay per group treatment visit 10% coinsurance per individual/ group visit after deductible $15 copay per visit (pre-authorization required) $20 copay per visit, deductible waived
(subject to pre-service review)
40% coinsurance per visit
(subject to pre-service review)
Inpatient $250 copay per admission - detoxification only 10% coinsurance per admission after deductible - detoxification only $250 copay per admission
(pre-authorization required)
20% coinsurance 40% coinsurance
Home Health No copay
Up to 100 visits/yr
No charge after deductible
Up to 100 visits/yr
$15 copay per visit
Up to100 visits/yr
20% coinsurance
Up to 100 visits/yr
40% coinsurance
Up to 100 visits/yr
Voluntary Sterilization N/A N/A No copay for women
$50 copay for men
N/A N/A
Physical Therapy $15 copay per visit 10% coinsurance after deductible $15 copay per visit up to 60-day period after injury 20% coinsurance up to 24 visits/yr 40% coinsurance up to $25 per visit, 24 visits/yr
Chiropractic Treatment $10 copay per visit up to 30 visits/yr $10 copay per visit up to 30 visits/yr $15 copay per visit up to 60 visits/yr 20% coinsurance up to 24 visits/yr 40% coinsurance up to $25 per visit, 24 visits/yr
Skilled Nursing Care No copay per admission 10% coinsurance per admission up to 100 days per benefit period No copay up to 100 days/yr 20% coinsurance up to 100 days per year 40% coinsurance up to 100 days per year