Summary Of Preferred Health Plan For
Jacobs Engineering Group Inc.
GULF SOUTH HEALTH PLANS
This summary is not intended to be a comprehensive Schedule of Benefits.
For complete information, please consult the Schedule of Benefits and Exclusions.
Eligible benefits payable by Health Plan are subject to prevailing allowable charge.
|
Physician Services
Doctor's Office Visits (Primary Care) Well-Child Care Referral Physician (Includes OB/GYN) |
$10 copayment per visit $10 copayment per visit $10 copayment per visit $5 additional co-payment at physician's office for Saturday, Sunday, Emergency or holiday visits. |
| Emergency Care Emergency Room Urgent Care |
$50 copayment per visit (Waived if admitted) $35 copayment per visit |
| Maternity Care Pre and Post-Natal Visits Delivery and Hospital Charges (including routine newborn care) |
$10 copayment per visit Covered in full |
| Hospital Inpatient Care Physician's/Surgeon's Services Room and Board X-ray, Lab and Diagnostic Tests Physical, Radiation and Inhalation Therapy |
Covered in full Covered in full Covered in full Covered in full |
| Hospital Outpatient Care Physician's/Surgeon's Services Same-Day Surgery Laboratory and X-Ray |
Covered in full Covered in full Covered in full Covered in full |
| Mental Health Care Inpatient
|
Payable at 80% of approved charges, maximum of 30 days per calendar year (Up to a maximum of 45 days per calendar year for selected diagnosis) $25 copayment per visit, maximum of 20 visits per calendar year (Up to a maximum of 52 visits per calendar year for selected diagnosis) |
| Alcohol and Substance Abuse Detoxification Rehabilitation Inpatient
|
Covered in full, maximum of 5 days per calendar year
|
| Other Services Hospice Care Extended Care Home Health Care Eye Exams (Ophthalmologist or Optometrist) Dental Equipment and Appliances Blood Administration Skilled Nursing Family Planning & Infertility Ambulance (if medically necessary) Outpatient Physical and Speech Therapy |
Covered in full Covered in full Covered in full $10 copayment per visit. Routine eye exams covered once every 2 years. Repair to sound, natural teeth damaged by injury or accident, $10 copay Payable at 80% of pre-approved charges, $800 max. per calendar year Covered in full Covered in full, limited to 100 days per calendar year Payable at 50% coinsurance $75 copayment - ground, $200 copayment - air $10 copayment per visit, limited to 60 consecutive visits per calendar year. |
| Pharmacy (Prescription Drugs purchased at a participating pharmacy)
|
$10 copayment per Generic prescription $20 copayment per Preferred Brand prescription $30 copayment per Non-Preferred Brand prescription Two times the amount of your prescription copayment, plus an ancillary charge when applicable for up to a 90 day supply |