| Description of Coverage - Select Plans |
| Plan Name | A |
B |
|
| Plan Type | HMO |
HMO |
|
| Hospital Deductible | $10,000 |
$10,000 |
|
Outpatient
Services |
|||
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 | Co-payment* |
||
Inpatient
Services |
|||
| Major Procedures and Surgeries | $400 - 1500 |
||
| Semi-private room, board, nursing care and meals | $500 X day for 5 days |
||
| 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 |
||
Maternity |
|||
| Maternity Services | Not
Covered |
||
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 | ||
| *The sum of all co-payments will not exceed $5,000.00 per member, except these limits are not applicable to co-payments for Emergency Care Services, Generic Prescription Legend Drugs, Specialty Pharmacy Agents, Primary Care Physician Office Copayments, and Second Medical Opinions. This is not a contract. All services must be pre-authorized by Health Plan, except for emergency care. For specific benefits, exclusions, co- payments and limitations, see the appropriate medical and hospitals services contract offered by Preferred Medical Plan, Inc. Above benefits are based on PMP FORM # PMP HOSP-1-CLD (2-08) ET.AL. Prices subject to change. You may contact PMP, if you have questions. | |||