HMO Flex Plan
Effective 7-1-2003
$35 Non Formulary
(Excluding Prescription Drug Copays)
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HMO Flex Plan |
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Effective 7-1-2003 |
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| Financial | In Network | |
| Deductible | None | |
| Lifetime Maximum Benefit | None | |
| Primary Care Physician Visits | ||
| Office Visit | $20 copay | |
| After Hours Office Visit | $25 copay | |
| Specialty Care | ||
| Office Visits | $20 copay | |
| Diagnostic Outpatient Testing | $20 copay | |
| Phys, Occ, Speech Therapy | $20 copay | |
| Outpatient Surgery | $200 copay | |
| Hospitalization | $500 copay | |
| Emergency Room | $100 copay | |
| Home Care | 100% | |
| Maternity | ||
| First OB Visit | $20 copay | |
| Hospitalization | $500 copay | |
| Mental Health | ||
| Inpatient | $500 - 30 days | |
| Outpatient | $20 copay - 40 visits | |
| Substance Abuse | ||
| Detoxification | $500 copay | |
| Inpatient Rehabilitation | $500 - 30 days | |
| Outpatient Rehabilitation | $20 copay - 30 visits | |
| Preventive Care | ||
| Routine Eye Exam | $20 copay | |
| Routine Physicals | $20 copay | |
| Immunizations | $20 copay | |
| Routine Mammography | $20 copay | |
| Routine GYN Exam | $20 copay | |
| Chiropractic Care | $20 copay 36 visits | |
| Prescriptions | $15-Generic, $20
Name Brand $35 Non Formulary |
|
| Durable Medical Equipment | 100% | |
| Referred Out-of-Pocket maximum
for co-pays (Excluding Prescription Drug Copays) |
$1,500 Single / $3,000 Family | |
Last updated 06/05/2007