NSA Medical

Medical Coverage

Blue Network S Medical Provider Network
Standard Medical Benefits	Behavioral Health Benefits
Prescription Drug Plan	Extended Well Care

Copay PPO Benefits
Benefit Features	Network Providers	Out-of-Network Providers
Annual Deductible
Individual	$2,500	$5,000
Family	$5,000	$10,000
Annual Out-of-Pocket Maximum Amount
Individual	$2,500	$7,500
Family	$5,000	$15,000
Dependent Age Limit	To age 24	To age 24
Lifetime Maximum Benefit	$5 Million	$5 Million
Benefits for Covered Services	Your Cost Through Network Providers	Out-of-Network Benefits
Practitioner Services
Office Visits	100% after $20 copay	80% after deductible
In-hospital Visits	100% after deductible	80% after deductible
Maternity Services	100% after deductible	80% after deductible
Routine Diagnostic Lab, X-ray, & Injections	100% after deductible	80% after deductible
Preventative Health Care Service
Well Child Care (to age 6)	100% after $20 copay	80% after deductible
Well Child Care (over age 6)	100% after $20 copay	80% after deductible
Annual Well Woman Exam	100% after $20 copay	80% after deductible
Annual Mammography Screening	100%	80% after deductible
Annual Cervical Cancer Screening	100%	80% after deductible
Prostate Screening	100%	80% after deductible
Well Care Screenings (all ages)	100% after $20 copay	80% after deductible
Immunizations/Injections (all ages)	100% after $20 copay	80% after deductible
Facility Services
Inpatient Services	100% after deductible	80% after deductible
Outpatient Surgery	100% after deductible	80% after deductible
Other Outpatient Services	100% after deductible	80% after deductible
Non-routine Diagnostic Services	100% after deductible	80% after deductible
Emergency Room Services	100% after deductible	80% after deductible
Medical Equipment
Durable Medical Equipment, Prosthetic and Orthotic Appliances	100% after deductible	80% after deductible
Therapeutic Services	100% after deductible	80% after deductible
Skilled Nursing Facility & Rehabilitation Services	100% after deductible	80% after deductible
Home Health Services	100% after deductible	80% after deductible
Hospice Services	100% after deductible	80% after deductible
Ambulance Services	100% after deductible	80% after deductible

10/20/35 Prescription Drug Plan
Brand Level	Member Pays
Generic Drugs	100% after deductible
Preferred Brand Name Drugs	100% after deductible
Non-preferred Brand Name Drugs	100% after deductible

Behavioral Health Benefits

Mental Health/Substance Abuse Treatment

Inpatient:
In-network - 100% after deductible
Out-of-network - 80% after deductible
Outpatient:
In-network -
Out-of-network -

Extended Well Care

The following is a list of items that are covered as a part of the annual preventative health exam for persons over the age of 6:

Annual health assessment
Immunizations
Blood pressure screening
Periodic cholesterol screening
Laboratory procedures to detect colon and rectal cancer
Periodic sigmoidoscopy
Flu shot
Tetanus-diphtheria (Td) booster
Pneumoccocal immunization
Other recommended adult immunizations and immunizations not completed in childhood
Other prescribed x-ray and lab screenings associated with preventative care
Speech and hearing screenings performed by the physician during the preventative health exam
Immunizations needed for travel to foreign countries

Note: This information is for guideline purposes only and may change at any time.