After a deductible of $250 per person ($500 family) for expenses incurred in a calendar year, the Plan pays benefits as set forth below. The out-of-pocket expense limit, excluding the deductible, is $1,000 per person ($2,000 family). This limit does not apply to dental, vision or prescription drug benefits, to expenses payable at 50%, to amounts over reasonable and customary, and non-covered services.
Most prescriptions are payable at 100% subject to the co-pay amount for each prescription or refill. You pay the co-pay directly to the pharmacy at the time of the purchase.
Generic Drug… $10; Name Brand (no generic available OR dotor orders no substitute)… $20; Name Brand (generic available)… $40
The Plan will pay reasonable and customary fees of licensed dentists up to a maximum of $1,200 per calendar year per person.
For Examinations, where your deductible does not apply, the Plan pays 80% of reasonable and customary charges per individual in any calendar year*.
For Frames, Lenses and Contact Lenses, there’s a $125 maximum per individual once in a calendar year*.
* The spans from January 1st through December 31st. Dates for examinations and for dispensing frames and lenses may differ. Benefits are once per calendar year. The date you take possession of frames, lenses or contact lenses will be the date the expense is incurred.
Immediate confidential assistance is available for health plan participants through the College Employee Assistance Program (or EAP) provider. The EAP provides employees and their dependents up to three (3) free counseling sessions per problem, per year. When further services are needed, referrals to covered providers can be made. Former information, visit the Chestnut Global Partner’s website and provide the username: icc.
All outpatient psychotherapy services must be performed by a psychiatrist (MD) or by a clinical psychologist. Services may also be performed by a licensed clinical social worker (LCSW) or a master’s prepared social worker (MSW) ONLY if it is under the direction of a psychiatrist or if services are obtained through a tax supported regional mental health center.