Quality Point of Service (QPOS)
Effective 7-1-2003
$35 Non Formulary
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Quality Point of Service (QPOS) |
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Effective 7-1-2003 |
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| Financial | In Network | Out of Network | ||
| Deductible | None | $500/$10000 | ||
| Co-Insurance | 20% | 70% - 30% | ||
| Co-Insurance Limit | $2500 - $5000 | $2500 - $5000 | ||
| Lifetime Maximum Benefit | None | $1,000,000 | ||
| Primary Care Physician Visits | ||||
| Office Visit | $25 copay | 70% after deductible | ||
| After Hours Office Visit | $25 copay | 70% after deductible | ||
| Specialty Care | ||||
| Office Visits | $25 copay | 70% after deductible | ||
| Diagnostic Outpatient Testing | $25 copay | 70% after deductible | ||
| Phys, Occupational, Speech Therapy | $25 copay | 70% after deductible | ||
| Outpatient Surgery | 20% Coinsurance | 70% after deductible* | ||
| Hospitalization | 20% Coinsurance | 70% after deductible* | ||
| Emergency Room | $100 copay | 100% copay | ||
| Home Care | 100% | 70% after deductible* | ||
| Maternity | ||||
| First OB Visit | $25 copay | 70% after deductible* | ||
| Hospitalization | 20% coinsurance | 70% after deductible* | ||
| Mental Health | ||||
| Inpatient | 20% coinsurance-30 Days | 70% after deductible* | ||
| Outpatient | $25 copay 40 visits | 50% after deductible* | ||
| Substance Abuse | ||||
| Detoxification | 20% coinsurance | 70% after deductible* | ||
| Inpatient Rehabilitation | 20% coinsurance 30 Days | NOT COVERED | ||
| Outpatient Rehabilitation | $25 copay 30 visits | NOT COVERED | ||
| Preventive Care | ||||
| Routine Eye Exam | $25 copay | NOT COVERED | ||
| Routine Physicals | $25 copay | NOT COVERED | ||
| Immunizations | $25 copay | NOT COVERED | ||
| Routine Mammography | $25 copay | 70% after deductible | ||
| Routine Gyn. Exam | $25 copay | 70% after deductible | ||
| Chiropractic Care | $25 copy 36 visits | 70% after deductible | ||
| Prescriptions | $15-Generic, $20
Name Brand $35 Non Formulary |
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| Durable Medical Equipment | 100% | 70% after deductible | ||
| Referred Out-of-Pocket Maximums | $2,500 Single - $5000 Family | |||
| * Member pre-certification required or benefits paid will be substantially less | ||||
Last updated 10/14/2003