HMO Super Value Plan
INSURANCE
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HMO FLEX PLAN
Point Of Service (POS)
Effective 7-1-2006
$35 Non Formulary
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HMO Super Value Plan |
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INSURANCE
HOME
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Effective 7-1-2006 |
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| Financial | In Network | |
| Deductible | None | |
| Co-Insurance (hospital in & out patient) | 20% | |
| Lifetime Maximum Benefit | None | |
| Primary Care Physician Visits | ||
| Office Visit | $25 copay | |
| After Hours home visit | $25 copay | |
| Specialty Care | ||
| Office Visits | $25 copay | |
| Diagnostic Outpatient Testing | $25 copay | |
| Phys, Occ., Speech Therapy | $25 copay | |
| Outpatient Surgery | 20% Coinsurance | |
| Hospitalization | 20% copay per admission | |
| Emergency Room | $100 copay | |
| Home Care | 100% | |
| Maternity | ||
| First OB Visit | $25 copay | |
| Hospitalization | 20% Coinsurance per admission | |
| Mental Health | ||
| Inpatient | 20% Coinsurance per Admission - 30 days | |
| Outpatient | $25 copay - 40 visits | |
| Substance Abuse | ||
| Detoxification | 20% coinsurance per admission | |
| Inpatient Rehabilitation | 20% coinsurance per admission - 30 days | |
| Outpatient Rehabilitation | $25 copay - 30 visits | |
| Preventive Care | ||
| Routine Eye Exam | $25 copay | |
| Routine Physicals | $25 copay | |
| Immunizations | $25 copay | |
| Routine Mammography | $25 copay | |
| Routine Gyn. Exam | $25 copay | |
| Chiropractic Care | $25 copy 36 visits | |
| Prescriptions | $15-Generic, $20
Name Brand $35 Non Formulary |
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| Durable Medical Equipment | 100% | |
| Referred Out-of-Pocket maximum for all co-pays and coinsurance. (Excluding Prescription Drugs) | $2,500 Single, $5000 family | |
Last updated 06/05/2007