Summary of Benefits
PHSTD1106

Major Copayment Provisions HIP Prime™
PCP Office visits $20 copay per visit
Specialist Office visits $20 copay per visit
Hospital admission $500 copay per admission
Emergency Room copay $50 copay per visit
Prescription drugs Not covered

 

Inpatient Hospital Services HIP Prime™
Hospital and physician services Subject to Hospital admission copay
Semiprivate room and board Included in Hospital admission copay
Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs, anesthesia, X-rays and lab tests Included in Hospital admission copay
Short-term speech, physical, occupational and respiratory therapy (when part of an acute admission) Included in Hospital admission copay
Short term only
Speech, physical, occupational and respiratory therapy (when part of a rehabilitation admission) Not covered
Radiation therapy and chemotherapy Included in Hospital admission copay
Pre-admission testing Included in Hospital admission copay
Human organ transplants Included in Hospital admission copay

 

Outpatient Medical Care HIP Prime™
PCP office visits Subject to PCP office visit copay
Specialists office visits Subject to Specialist office visit copay
Preventive care, including physical exams, eye and eye exams, health education and counseling, pap smear, mammography and immunizations Included in PCP office visit copay
Well-child care to age 19 including immunizations No copay
Diagnostic services including X-ray, lab tests, EKG's, MRI's and CAT scans Included in PCP office visit copay
Prenatal, postnatal care in physician's office No copay
Outpatient hospital services and ambulatory surgery including physician and facility services $75 copay per visit
Second medical and surgical opinion No copay
Disposable medical supplies No copay
Wheelchairs Not covered
Routine foot care Not covered
Chiropractic services Subject to Specialist office visit copay

 

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
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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