Health Advantage HMO Benefit Summary 2006-2007
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Your Copayment*
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Your Coinsurance**
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Preventive Care Services |
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Physical Exams, Adults (visit only) |
$0 copayment |
0% coinsurance |
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Well Baby/Child Care |
$0 copayment |
0% coinsurance |
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Children's Immunizations |
$0 copayment |
0% coinsurance |
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Preventive Dental - one every 6 months |
$25 copayment |
0% coinsurance |
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Vision Exam - one every 24 months |
$25 copayment |
0% coinsurance |
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Annual Gynecological Visit |
$0 copayment |
0% coinsurance |
Routine Mammogram
(no referral required to in-network providers) |
$0 copayment |
0% coinsurance |
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Physician Services |
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PCP Visits |
$20 copayment |
0% coinsurance |
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Specialist Visits |
$25 copayment |
0% coinsurance |
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Inpatient Medical Care |
$0 copayment |
10% coinsurance |
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Outpatient Surgical Care |
$0 copayment |
10% coinsurance |
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Allergy Services |
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Specialist Visits |
$25 copayment |
0% coinsurance |
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Injections or Serum |
$0 copayment |
10% coinsurance |
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Outpatient Services |
Diagnostic Testing
(lab and X-ray) |
$0 copayment |
10% coinsurance |
Surgical Services
(facility charge) |
$100 copayment |
0% coinsurance |
Emergency Room
Visit |
$100 copayment
(waived if admitted
to same hospital) |
0% coinsurance |
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Urgent Care Center/ER After-hours Clinic Visit |
$100 copayment
(waived if admitted
to same hospital) |
0% coinsurance |
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Ambulance (land or air) |
$1,000 maximum per year
(Limitation applies to transport charges only.) |
$0 copayment |
0% coinsurance |
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Home Nurse Visits |
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120 visits per year |
$0 copayment |
0% coinsurance |
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Home Infusion IV Drugs/Solutions |
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$0 copayment |
10% coinsurance |
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Physical, Occupational, Speech Therapy and Chiropractic Services |
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Limit of 15 visits per therapy, per member, per year |
$0 copayment |
20% coinsurance |
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Inpatient Hospital |
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(unlimited days at semiprivate room rate) |
$250 copayment
per admission
(maximum: 3 copays per year, per person) |
10% coinsurance |
Inpatient Rehab
Limited to 60 days per year |
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Maternity Services |
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Initial Specialist Visit |
$20 copayment |
0% coinsurance |
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OB Services |
$0 copayment |
10% coinsurance |
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Hospital Services (facility fee) |
$250 copayment
per admission |
10% coinsurance |
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Inpatient Physician Services |
$0 copayment |
10% coinsurance |
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Outpatient Diagnostic Testing (lab and X-ray) |
$0 copayment |
10% coinsurance |
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Organ Transplant Services |
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(Except kidney and cornea; Transplants must be authorized in advance by Health Advantage;
2 transplants per member per lifetime.) |
$500 inpatient hospital copayment per admission |
20% coinsurance |
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Durable Medical Equipment (DME) and Medical Supplies |
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$10,000 maximum per year |
$0 copayment |
20% coinsurance |
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Prosthetic and Orthotic Devices |
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$15,000 maximum per year |
$0 copayment |
20% coinsurance |
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TMJ |
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$500 lifetime maximum |
$25 copayment |
0% coinsurance |
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Mental Health/Substance Abuse |
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Not covered by Health Advantage.
Benefits administered and claims paid by
CORPHEALTH.
Call 1-866-378-1645 for coverage information.
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Prescription Drugs |
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Not covered by Health Advantage.
Benefits administered and claims paid by
National Medical Health Card RX.
Access National Medical Health Card RX at
www.nmhcrx.com.
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**Coinsurance is applied after copayment.
Only services performed, prescribed, directed or authorized in advance by the primary-care
physician and Health Advantage are covered benefits, except for emergency care.
All payments are based on the Health Advantage maximum allowable amount. Charges
exceeding the Health Advantage maximum allowable amount do not apply toward annual
out-of-pocket limits. Member may be responsible for charges in excess of any dollar
maximum.
This benefit summary provides a brief description of your public school benefits
for the Health Advantage HMO Plan. Health Advantage is a claims administrator under
the direction of the Employees Benefit Division. For a complete description of your
benefits, please refer to the Summary Plan Description published by Employee Benefits,
your group administrator.