MODEL 113: DEPENDENTS OF ASSOCIATION EMPLOYEES
Plan 16
Plan payments may not exceed Usual, Customary and Reasonable (UCR) charges
BENEFIT
* WABASH PAYSAllergy Testing & Injections 100%
Ambulance Transportation in Emergency Base Rate 100%
Anesthesia 100% in-network, 85% non network
Appliances/Braces/Trusses 100% up to $125.00 per item
Cardiac/Pulmonary Rehabilitation 100% up to 30 outpatient treatments or 30 inpatient days
Chemotherapy/Radiation Therapy for cancer 100%
Colostomy Bags (only) 50% reimbursement
Dental Care required due to accidental injury 100% up to $300.00 per year
Diagnostic Testing (outpatient lab, x-ray, etc.)100% up to $3000.00, then 80% to max. of $10,000.00 per year
Dialysis 100% up to $5,000 then 80% to max of $10,000 per year
Short Term Peritoneal dialysis 100% up to $4,000 per year
Dietary Consultation up to $50.00 once per year
Eye Exam (routine) $40.00 once per year (Does not apply to Active Railroad Employees covered by VSP
Hearing Aids (hearing loss must be greater than 35 dB) 80%
Hearing Test (must be under physician supervision) 80%
Home Health Care 100% for up to 40 visits per year. No limit on visits if patient is terminal
Hospice- Home Care Inpatient Respite Care Covered under Home Health Care 100% up to $3000.00
Hospital Emergency Room 100% if an emergency
Emergency Room Physician 80% if deemed non-emergent
Hospital:
Inpatient (must pre-notify Assn. at 1-888-800-9161) 100% at
semi-private rate for up to 183 days per calendar year in-network, 80% at
semi-private rate for up to 183 days per calendar year out-of -network
Outpatient (excluding Diagnostic Testing covered under separate
benefit) 100% in-network 80% out-of-network
Injections 100% (purchased through Pharmacy)
Lab & X-ray Professional Fees when
confined as a hospital inpatient 100% In-network
Oxygen- when ordered
by a physician for patients who meet medical necessity guidelines 100% to
a max. of $3,000.00 per calendar year
Penile Erection Device (external) 75%
Penile Implant 80%
Physical Therapy100% up to 15 treatments per calendar year with doctor's order additional treatments must be pre-certified.
Physician Services: (office visits, hospital visits, surgery, podiatry, etc.) 100% in-network 85% out-of-network
Preventive Services (routine physicals, immunizations e.g., flu, pneu, childhood shots) 100% in-network 85% out-of-network
Prosthetics:
breast prosthesis 80% after $100.00 deductible
artificial limb 60% to a max. of 4,000.00 after a deductible of $500.00 per item (renews after 5 years)
Psychiatric
Inpatient:
(must be pre-certified) Same as any other
illness
Outpatient: maximum of 15 visits per year
paid at:100% in-network 85% out-of-network
Skilled Nursing Facility $100 deductible. Must be within 14 days of a hospital inpatient stay of at least 3 days
Sterilization (Surgical, male or female) 100% in-network 85% out-of-network
Stress Tests (including Thallium Stress Test) 100% in-network 85% out-of-network
Substance Abuse/Chemical
Dependency:
Inpatient (must be pre-certified) First Admission: 100% up to $5,000.00,
then 80% limited to 30 days. Second Admission:100% up to $5,000.00, then 80%
limited to 30 days (Maximum of two
admission per lifetime)
Temporomandibular Joint Syndrome
(TMJ) Treatment 50% to a lifetime max. of $1,250.00 after a $50.00
deductible
Surgery 100% in-network 85% out-of-network
Weight Loss Program (must be medically supervised) 80% up to a maximum of $3,000.00 after a $100.00 deductible, lifetime benefit.