| Description of Coverage - Elite Plans |
| Plan Name | A |
B |
C |
| Hospital Deductible | $2,000 |
$2,000 |
$2,000 |
Outpatient
Services |
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Primary Care
Physician (PCP) |
$25 per visit PCP at Contracted Plan A PCP Offices |
$25 per visit PCP is chosen from PMP Directory Network |
|
Referred Specialists |
$50
per visit |
||
Surgical Services |
No
charge |
||
Treatment rooms
and all appropriate equipment |
No
charge |
||
| Application, changes, removal of dressings, splints, plaster cast and removal of sutures | No
charge |
||
| Medical supplies for use at Provider's Office/Facility | No
charge |
||
| Laboratory Examinations and Services | No
charge |
||
| Periodic physical examinations | No
charge |
||
| Well child care and pediatric services | No
charge |
||
| Health Education | No
charge |
||
| Immunizations | $10
per Vaccine/Immunization Agent |
||
| Allergy Testing | $50
per visit |
||
| Allergy Visits & Immunotherapy | $10
per visit |
||
| Podiatry Services | $10
per visit |
||
| Chiropractic Services | $10
per visit |
||
| Routine Vision and Hearing Examinations | $10
per visit |
||
| Therapeutic and Diagnostic Services | $0-$400 |
||
Inpatient
Services |
|||
| Major Procedures and Surgeries | $400 - 1500 |
||
| Semi-private room, board, nursing care and meals | $500 X day for 5 days |
$0 |
|
| Intensive, critical, special and coronary care units | Co-payment* |
||
| Operating, treatment and recovery rooms | No
charge |
||
| Drugs, medicine, intravenous injections and solutions prescribed by attending Physician for use in the Hospital | No
charge |
||
| Medical supplies for use in the hospital | No
charge |
||
| Oxygen and its administration | No
charge |
||
| Laboratory examinations, electrocardiograms and inhlation therapy | No
charge |
||
Emergency
and Urgent Care (UC) Services |
|||
| Urgent Care Services | $40
per visit after regular office hours at Contracted UC Centers |
||
| Emergency | $100 per Emergency plus 25% of charges above $100. Emergency Services and Hospital Stays initiated through the Emergency Room, including Ambulance Service |
$250 per visit | |
Maternity |
|||
| Maternity Services | $1,500 Co-Payment. 15 months Waiting Period. *** Deductible Does Not Apply *** |
||
Prescriptions |
|||
| Generic Prescriptions Only, except non-generic, non-prescriptions and contraceptives | $10/$15/$20/$30/50%
per prescription at Contracted Pharmacies |
||
Optional
Riders |
|||
| Vision | add $5.00 / month | ||
| Dental | add $6.00 / month | ||
Annual Deductible that applies to services listed above is $2,000 per Member per calendar year. Maximum annual out-of-pocket costs is $5,000 per Member per calendar year, not including any amount paid toward the fulfillment of the Deductible as well as copayments for Emergency Services and Care, and other services outlined in the applicable Attachment A, Schedule of Benefits and Covered Services. Total dollar annual benefit for essential benefits is $1,250,000 per Member per policy year. This is not a contract. All services must be pre-authorized by the Health Plan, except for Emergency Care. For specific benefits, exclusions, copayments and limitations, see the applicable Individual Medical and Hospital Services Contract offered by Preferred Medical Plan, Inc. 4950 SW 8th Street, Coral Gables, FL 33134. Above benefits are based on FORM NO. PMP-HOSP-1-(12/11) and ATT-A-(12/11), et. al for Plans R2A, R2B; R2BB & R2C. Prices subject to change. You may contact PMP at (305) 648-4015, if you have questions. *Under the Affordable Care Act, certain preventive services will be covered without you having to pay a copayment or coinsurance. Please refer to FORM NO.PMP-HOSP-1-ATT-A-(12/11) for Plans R2A, R2B; R2BB & R2C for details. |
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