|
Summary of Benefits
PHSTD1962
| Major
Copayment Provisions |
HIP
Prime |
| PCP Office visits |
$15 copay per visit |
| Specialist Office visits |
$15 copay per visit |
| Hospital admission |
No copay |
| Emergency Room copay |
$35 copay per visit |
| Prescription drugs |
$10 generic/$20 brand (Subject
to Drug Formulary)
$40 for Non-Formulary |
| Inpatient
Hospital Services |
HIP
Prime |
| Hospital and
physician services |
No copay |
| Semiprivate room
and board |
No copay |
| Operating and
recovery room, intensive and special care units, general nursing care,
prescribed drugs, anesthesia, X-rays and lab tests |
No copay |
| Short-term speech,
physical, occupational and respiratory therapy (when part of an acute
admission) |
No copay
Short term only |
| Speech, physical,
occupational and respiratory therapy (when part of a rehabilitation
admission) |
No copay
90 days per calendar year |
| Radiation therapy
and chemotherapy |
No copay |
| Pre-admission
testing |
No copay |
| Human organ
transplants |
No 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
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 |
No copay |
| 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 |
No copay;
30 days per calendar year |
| Outpatient |
$25 copay;
20 visits per calendar year |
| Alcohol
and Substance Abuse Care |
|
| Inpatient
detoxification |
No copay;
7 days per calendar year |
| Inpatient
Rehabilitation Treatment |
Not covered |
| Outpatient
Rehabilitation Treatment |
Subject to PCP 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; 200 visits
per calendar year |
| Hospice care |
No copay; 210 days |
| Skilled Nursing
Facility care |
No copay; Unlmited
days |
| Dialysis
treatment |
$15 copay per visit |
| Diabetes
equipment, supplies and education |
$15 copay per month |
| Outpatient
physical, speech, occupational and respiratory therapy |
Subject to
Specialist office visit copay;
90 visits per calendar year |
| InterPlan® Care |
Covered (Chronic
conditions only) |
| 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 |
| 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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