MODEL 112: ASSOCIATE MEMBER - OPTIONAL PLAN
Plan 15
BENEFIT
* WABASH PAYSAllergy Testing & Injections 80%
Ambulance Transportation in Emergency Base Rate 80%
Anesthesia 80%
Appliances/Braces/Trusses 80%
Cardiac/Pulmonary Rehabilitation 80% up to 30 outpatient treatments or 30 inpatient days
Chemotherapy/Radiation Therapy for cancer 80%
Colostomy Bags (Only) 50% reimbursement
Dental Care required due to accidental injury 80%
Diagnostic Testing (outpatient lab, x-ray, etc.) 80%
Dialysis 80%
Dietary Consultation up to $50.00 once per year
Eye Exam (routine) $40.00 once per year
Flu Shots 80%
Hearing Test (must be under physician supervision) 80%
Hospital Emergency Room 80% if an emergency, 64% if deemed non-emergent
Hospital:
Inpatient (must pre-notify WMHA 1-888-800-9161) 80% at semi-private rate in-network 64% at semi-private rate
out-of-network
Outpatient (excluding Diagnostic Testing
covered under 80% in-network separate benefit) 64% out-of-network
Injections 80%
Lab & X-ray Professional Fees when
confined as a hospital inpatient 80%
Magnetic Resonance Imaging (MRI) 80%
Mammogram (screening) 80% (one per year)
Penile Erection Device (external) 80%
Penile Implant 80%
Physical Therapy 80%
Physician Services: (office visits, hospital visits, surgery, podiatry, etc.) 80%
Preventive Services (routine physicals, immunizations) 80%
Prosthetics: breast prosthesis 80%
Psychiatric
Inpatient:
80% up to 30
day maximum
Outpatient: maximum of 15 visits per year
paid at:80%
Scans 80%
Sterilization (Surgical) 80%
Stress Tests (including Thallium Stress Test) 80% in-network
Substance Abuse/Chemical
Dependency:
Inpatient (must be pre-certified) 80% up to $4,000.00 (Maximum of one
admission per lifetime)
Temporomandibular Joint Syndrome
(TMJ) Treatment 80% Not Covered: (1) Chiropractic Care (2) Durable Medical Equipment (DME) (3) Hearing Aids (4) Home Health Care (5) Hospice (6) Oxygen (7) Prescription Medications (8) Skilled Nursing Facility (9) Transplantation of Vital Organs (10) Weight Loss Program
Surgery 80%