"Ultra Value Plus" Summary of Benefits:

Your Cost:

• Office/Specialist Visits. Preventive Care. Physical Exams. Well-Baby/Child-Care. Allergy Tests/Treatment. Eye Exams. Immunizations. Nutrition Counseling. Hearing Evaluations.
• Laboratory & X-ay services
• MRIs, CAT Scans & Other Diagnostic Services

• $10 copay per visit. No copay for primary and preventive care to age 19. No copay for Rap smear or mammography screening.
• $10 copayment for lab tests or X-rays. $10 per-day maximum for all tests performed at the same location.
• $10 copayment

• Surgeon & Physician Fees, Semi-private Room & Board as medically necessary, Operating & Recovery Room Fees. Intensive & Special Care Units, X-rays/Lab Tests, Anesthesia. Prescribed Drugs, Therapy (Physical limited to first 30 days of each admission. Radiation. Chemotherapy)

• $500 copayment per confinement, plus $200 or 20% (whichever is less) for surgical services

• $75 copayment for the facility, plus $200 or 20% (whichever is less) for surgical services

• Physician's Hospital Visits
• Newborn Nursery Care

• (whichever is less) for delivery.
• Covered in full.
• Routine, well-baby care not covered. Non-routine, sick-baby

• Ambulance Service
• Hospital Emergency Room
• Urgent Care Facility

• 50% coinsurance, 20% for air ambulance
• $50 copayment for emergency room (waived if admitted)
• $10 copay per visit to your HIP Medical Centre or a HIP Treatment Centre when your centre is closed, $35 copay per visit to a freestanding urgent care facility.

• Covered in full, in lieu of hospitalization. Physical therapy is limited to the first 30 days of each admission. There is custodial.

• 100 visits per calendar year covered in full, in lieu of hospitalization

• Covered in full up to 210 days

• Inpatient- Up to 30 days per member per calendar year for detoxification. Inpatient detoxification and inpatient Mental Health services are limited to a combined total of 30 days per calendar year.
• Outpatient- Up to 60 visits per member per calendar year for alcohol and drug rehabilitation. HIP Mental Health services must be used for the Alcohol Rehabilitation services. HIP must act as the referral source for the Drug Rehabilitation Services.

• 50% coinsurance
• $10 copayment per visit

• Inpatient- Up to 30 days per member per calendar year, including psychiatrist or psychologist services. Inpatient Mental Health and inpatient Detoxification services are limited to a combined total of 30 days per calendar year.
• Outpatient- Up to 20 visits per member year. HIP Mental Health Centres must be used.

• 50% coinsurance
• $25 copayment per visit

• Per 30 days supply: $10 copayment for insulin. $10 copayment for supplies. For equipment: $10 copayment per item.

• Dependent children covered to age `9, end of month. Full-time students covered to age 23, end of year.

• One cleaning per calendar year per member
• One application of fluoride for children up to and including age 15
• Two oral examination per calendar year per member
• Two bitewing X-ray every six months

• $5 per member for the cleaning. $5 per member for all other services performed at the same visit. The most you will pay is $10 per visit. These services must be provided by an HIP participating dentist.

• $50 deductible, $10 generic, $20 brand after deductible is met.

General exclusions: General dental care, cosmetic surgery, custodial care, benefits covered by Worker's Compensation and No Fault Auto Insurance.