IBEW Local 413
Benefits Web site
IBEW Local 413
Benefits Web site
| Copayment Maximum | $2,000 per individual / $4,000 per family |
| Professional Services | |
|---|---|
| Physician Services - outpatient Physician and authorized specialist office visits Allergy testing or treatment |
$15/visit $15/visit |
| Access+ Specialist | $30/visit |
| Laboratory, X-ray and diagnostic tests | no charge |
| Preventive care Routine physical exam Eye/ear screenings and immunizations according to age schedule |
no charge no charge |
| Outpatient Services | |
| Surgery performed in a Participating Ambulatory Surgery Center (ASC) | $150/surgery |
| Outpatient Surgery in a hospital/facility | $150/surgery |
| Outpatient treatment and necessary supplies | no charge |
| Hospitalization Services | |
| Inpatient physician services, including pregnancy and maternity care | no charge |
| Semi-private room and board, medically necessary services and supplies | $500/admission |
| Skilled nursing facility(SNF) services | $100/day |
| Emergency Health Coverage | |
| ER facility services (waived if admitted directly as inpatient) | $100/visit |
| ER physician visits | no charge |
| Mental Health Services | |
| Inpatient | $500/admission |
| Outpatient (severe) | $15/visit |
| Outpatient (non-severe) (up to 20 visits per calendar year combined with outpatient chemical dependency visits) | $25/visit |
| Chemical Dependency Services (Substance Abuse) | |
| Inpatient Services for medical acute detoxification | See Hospitalization Services |
| Outpatient Visits (up to 20 visits per calendar year combined with outpatient non-severe mental health visits) | $25/visit |
| Prescription Drugs | |
| Retail Prescriptions (up to 30-day supply) | $10/Generic $20/Formulary $35/Non-Formulary |
| Mail Service (up to 90-day supply) | $20/Generic $40/Formulary $60/Non-Formulary |
| Injectables (self-administered) | 20% (up to $100 copayment maximum per prescription) |
This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.