Summary of Benefits
PHSTD1103

Mental Health and Alcohol and Substance Abuse Care HIP Prime™
Mental Health Care  
Inpatient Subject to Hospital admission copay;
30 days per calendar year
Outpatient $35 copay per visit;
20 visits per calendar year
Alcohol and Substance Abuse Care  
Inpatient detoxification Subject to Hospital admission copay;
7 days per calendar year
Inpatient Rehabilitation Treatment Not covered
Outpatient Rehabilitation Treatment Subject to Specialist office visit copay;
60 visits per calendar year

 

Special Kinds of Care HIP Prime™
Emergency and Urgent Care  
In hospital emergency room Subject to Emergency Room copay
In urgent care facility Subject to PCP office visit copay
In physician's office Subject to PCP office visit copay
Ambulance service to hospital No copay
Home health care No copay; 40 visits per calendar year
Hospice care No copay; 210 days
Skilled Nursing Facility care No copay; 30 days per calendar year
Dialysis treatment $20 copay per visit
Diabetes equipment, supplies and education $20 copay per month
Outpatient physical, speech, occupational and respiratory therapy Subject to Specialist office visit copay;
30 visits per calendar year
InterPlan® Care Urgent/Some Specialty care covered
Family Planning Services Covered
Dental Care
General Dental Care Covered at reduced member fee schedule
Preventive Dental Oral exam (One every 6 months - $5 copay per visit
Cleaning, including one application of flouride for children age 16 and under (one every 6 months - $10 copay per visit)
Durable Medical Equipment Not covered
Private Duty Nursing Not covered
Hearing Aids Not covered, Cochlear implants covered
Optical Care
Refractive Eye Exams No copay per visit
Eyeglasses $45 for a complete paid every 24 months

 

Footnotes
Drugs are dispensed in accordance with HIP's Drug Formulary. Please refer to your Prescription Drug Rider for details. 

Except for emergency care, the above benefits and services are covered only when provided or referred by a HIP Primary Care physician and/or approved in advance by the HIP Member Advocacy Program. HIP Participating Physicians and Providers have contracted with HIP to provide care to our members; they are not employees, agents, servants or representatives of HIP. This summary is provided for information only; it does not contain complete details of the Plan which are available only in the Contract or Certificate of Coverage and Schedule of Benefits, and it does not constitute an Agreement.

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