BlueCare HMO Schedule of Copayments - Lake County

lakecountyfl.gov
  • No tags were found...

BlueCare HMO Schedule of Copayments - Lake County

- HMO PlanSchedule of Copayments Plan 15- GrandfatheredAll Copayments are subject to the maximum Copayment limitations described in the Benefit Booklet.The following description of Services is not intended to create, and shall not create, any rights orobligations that differ from or are inconsistent with those set forth elsewhere in the Member Handbook.Out-of-PocketBenefit DescriptionCost to MemberMaximum Out-of-Pocket (per Benefit Period)Single $2,000Family $4,000Physician ServicesPrimary Care Physician (PCP)Benefit DescriptionCost to Member$20 CopaymentSpecialist$35 CopaymentIn-office SurgeryAllergy InjectionSubject to PCP or SpecialistCopayment, whichever isapplicable$0CopaymentAllergy TestingPrimary Care PhysicianSpecialistAnnual Contracting Gynecologist$20 Copayment$35 Copayment$35 CopaymentMaternity – initial obstetrician visit only$20 CopaymentWell Child Care Services$0 CopaymentLarge Group NFQ Plan 15Lake County Board of County CommissionersDivisions 002 c02 r02 r04 003 c03 r05 r06 005 c05 r09 r10 007 c07 r13 r14 009 c09 r17 r18 011 c11 r21 r22 014 c14 r31 r32 016 c16 r35 r361


Inpatient ServicesBenefit DescriptionCost to MemberInpatient HospitalInpatient Physician$200 Copayment per day forday 1-5,$1,000 maximum/Admission$0 CopaymentInpatient Rehabilitation Services (e.g., Physical, Speech, Cardiac, orOccupational)$0 CopaymentOutpatient ServicesBenefit DescriptionSurgical - Outpatient Hospital SurgicalCost to Member$200 CopaymentSurgical - Ambulatory Surgical Center$200 CopaymentDialysis$0 CopaymentDiagnostic Lab and X-ray at Hospital or a Free Standing FacilityDiagnostic Testing at Hospital or a Free Standing Facilityincluding MRI,CT Scans, Endoscopy and Stress TestsBirthing Center$15 Copayment$200 Copayment$0 CopaymentEmergency Services and Care (*Copayment waived if admitted)Benefit DescriptionEmergency Room in a Contracting HospitalEmergency Room in a Non-Contracting HospitalUrgent Care in a Contracting Urgent Care CenterAmbulance (Medically Necessary)Cost to Member$100 Copayment*$100 Copayment*$30 Copayment$0 CopaymentLarge Group NFQ Plan 15Lake County Board of County CommissionersDivisions 002 c02 r02 r04 003 c03 r05 r06 005 c05 r09 r10 007 c07 r13 r14 009 c09 r17 r18 011 c11 r21 r22 014 c14 r31 r32 016 c16 r35 r362


Behavioral Health ServicesBenefit DescriptionCost to MemberMental Health and Substance Dependency Treatment ServicesOutpatient Facility Services rendered at:Emergency Room (Copayment waived if admitted)Contracting HospitalNon-Contracting Hospital$100 Copayment$100 CopaymentHospital$200 CopaymentPhysician Services at a Hospital and ERPhysician and other health care professionals licensed to performsuch Services rendered at:PCP OfficeContracting Specialist Office$0 Copayment$20 Copayment$35 CopaymentAll other locationsPCPContracting Specialist$0 Copayment$0 CopaymentInpatientFacility Services$200 Copayment per day for day1-5,$1,000 maximum/AdmissionPhysician and other health care professional Services$0 CopaymentLarge Group NFQ Plan 15Lake County Board of County CommissionersDivisions 002 c02 r02 r04 003 c03 r05 r06 005 c05 r09 r10 007 c07 r13 r14 009 c09 r17 r18 011 c11 r21 r22 014 c14 r31 r32 016 c16 r35 r363


Special ServicesBereavement CounselingBenefit DescriptionCost to Member$0 CopaymentNote: $250 or 6 visits Per Member Per LifetimeBiofeedback$0 CopaymentColonoscopies (Routine)Contracting ProviderNon-contracting ProviderDurable Medical EquipmentHome Health Care$0Not Covered$0 Copayment$0 CopaymentNote: 40 Days Per Member Per BPHospice Care$0 CopaymentMammograms (Routine and with diagnosis)Contracting ProviderNon-Contracting ProviderOutpatient Private Duty Nursing$0Not Covered$0 CopaymentNote: 40 Visits Per Member Per BPProsthetic & Orthotic DevicesRehabilitation Services (e.g., Outpatient Physical, Speech, Cardiac,or Occupational)Skilled Nursing Facility90 Days/Benefit Period$0 Copayment$20 Copayment/visit$0 Copayment per daySecond Medical OpinionServices rendered by a Contracting ProviderServices rendered by a Non-Contracting ProviderTMJ ServicesNote: 18 visits Per Member per BPWig (after chemotherapy)$35 Copayment40% of Allowance$0 Copayment$0 CopaymentLarge Group NFQ Plan 15Lake County Board of County CommissionersDivisions 002 c02 r02 r04 003 c03 r05 r06 005 c05 r09 r10 007 c07 r13 r14 009 c09 r17 r18 011 c11 r21 r22 014 c14 r31 r32 016 c16 r35 r364


Benefit MaximumsUnless specifically noted otherwise, benefit maximums apply per person and accumulate on a BenefitPeriod basis, as indicated below.Bereavement Counseling Per Covered Plan ParticipantPer Lifetime .................................................................................. 6 visits not to exceed a maximum of $250Home Health Care Days Per Covered Plan Participant Per BP ................................................................ 40Outpatient Private Duty Nursing Visits Per Covered Plan Participant Per BP ........................................ 40Spinal Manipulations Visits Per Covered Plan Participant Per BP .......................................................... 26TMJ Visits Per Covered Plan Participant Per BP ........................................................................................ 18Transplant Coverage for Lodging, Meals and TransportationPer Covered Plan Participant Per Lifetime ......................................................................................... $10,000Large Group NFQ Plan 15Lake County Board of County CommissionersDivisions 002 c02 r02 r04 003 c03 r05 r06 005 c05 r09 r10 007 c07 r13 r14 009 c09 r17 r18 011 c11 r21 r22 014 c14 r31 r32 016 c16 r35 r365

More magazines by this user
Similar magazines