The Health Plan provides coverage for medical services from network health care providers and non-network health care providers, subject to deductibles, copayment and coinsurance. To maximize your benefits and reduce out-of-pocket costs, choose doctors and other health care providers
within the AFTRA Health Plan’s preferred provider organization (PPO) networks.
| Network providers | |
| | $10 per office visit.
|
| | $200 for each individual; $400 maximum per family. |
| | 90% of the scheduled allowance for each individual's first $10,000 in covered expenses per year after the deductible; 100% thereafter. Excludes copayment.
|
| | 10% of the scheduled allowance for each individual's first $10,000 in covered expenses per year after the deductible. |
- Annual out-of-pocket limit
| $1,000 per individual (plus deductible and copayment).
|
| Non-network providers | |
| | $10 per office visit.
|
| | $400 for each individual; $800 maximum per family. |
| | 60% of the scheduled allowance for each individual's first $8,000 in covered expenses per year after the deductible; 100% of the scheduled allowance for covered expenses thereafter. Excludes copayment.
|
| | 40% of the scheduled allowance for each individual's first $8,000 in covered expenses per year after the deductible.
|
- Annual out-of-pocket limit
| $3,200 per individual (plus deductible, copayment, and expenses that exceed the scheduled allowances).
|
Refer to the 2011 Health Plan SPD and relevant Benefits Updates for additional information and details.The information provided above is summarized and is not a complete description of the actual terms and provisions of the Health Plan documents. If any conflict arises between this information and the Plan documents, or if any point is not discussed above or is only partially discussed, the Plan documents will govern in all cases.