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

Casts and Dressings


Covered in full

Covered in full

Covered in full

Covered in full
Mental Health Care
Inpatient


Outpatient


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


Outpatient


Covered in full, maximum of 5 days per calendar year


Payable at 80% of approved charges, maximum 30 days per calendar year (Limited to 1 episode of care per lifetime)

$25 copayment per visit, maximum 20 visits per calendar year (Limited to 1 episode of care per lifetime)

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)


Mail Order

$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