| Ice Blended Medical Plan |
| Covered Charges |
In-Network Providers |
Non-Network Providers |
| Deductible Per Covered Person |
$250 |
$3,000 |
| Deductible Per Family Unit |
$500 |
$6,000 |
| Maximum Out-Of-Pocket Amount Per Calendar Year - Copays and Deductibles do not apply to the Calendar Out-Of-Pocket Maximum |
| Per Covered Person |
$3,500 |
$10,000 |
| Per Family Unit |
$7,000 |
$20,000 |
| Office Visits |
100% after $15 Copayment |
50% after deductible |
| Specialist Office Visit |
100% after $30 Copayment |
50% after deductible |
| Laboratory, X-Rays & Diagnostic Testing - In conjunction with an Office Visit |
100% after deductible |
50% after deductible |
| Preventive Care |
| Routine Well Care |
100% |
Not Covered |
| Includes: office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x-rays, laboratory blood tests, colonoscopies, bone density tests, hearing tests, vision tests, well child care, and immunizations/flu shots. |
| Frequency limits for: |
| Mammograms ages 40 and over . . . . . . . . . . . . . . annually |
| Colonoscopies and bone density tests ages 40 and over . . . . . . every 24 months |
| Routine Well Newborn Care |
100% |
50% after deductible |
| Urgent Care & Emergency Room |
| Urgent Care Facility |
100% after $30 Copayment |
50% after deductible |
| Emergency Room - Facility |
100% after a $250 Co-pay |
50% after deductible |
| Emergency Room - Physician |
80% after deductible |
50% after deductible |
| The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency basis. The utilization review administrator must be notified within 48 hours of the admission, even if the patient is discharged within 48 hours of the admission. |
| Out Patient Procedures |
| Outpatient Surgery Center |
100% after $200 copayment after deductible |
50% after deductible |
| Physician Out Patient Services |
80% after deductible |
50% after deductible |
| Second Surgical Opinion |
100%, deductible waived |
50% after deductible |
| Hospitalization & Surgeries |
| Room and Board, necessary services and Supplies |
100% after $200 copayment per day, $600 maximum per confinement |
50% after deductible - semiprivate room rate |
| Inpatient Hospital Visits |
Inpatient visits 80% after deductible |
50% after deductible |
| Mental Disorders and Substance Abuse |
| Inpatient |
100% after $200 copayment per day, $600 maximum per confinement |
50% after deductible - semiprivate room rate |
| Outpatient |
100% after $15 copayment and deductible |
50% after deductible |
| Costco Pharmacy |
Contracted Retail Pharmacy |
| Generic |
You pay the lesser of $5 or the total cost of the prescription |
You pay the lesser of $10 or the total cost of the prescription |
| Formulary Brand Drugs |
You pay the lesser of $10 or the total cost of the prescription |
You pay the lesser of $20 or the total cost of the prescription |
| Non-Formulary Brand Drugs |
You pay the lesser of $20 or the total cost of the prescription |
You pay the lesser of $35 or the total cost of the prescription |
