|
|
Your Copayment*
|
Your Coinsurance**
|
|
Preventive Care Services |
|
Physical Exams, Adults (visit only) |
$0 copayment |
0% coinsurance |
|
Well Baby/Child Care |
$0 copayment |
0% coinsurance |
|
Children's Immunizations |
$0 copayment |
0% coinsurance |
Annual Gynecological Visit
(no referral required for in-network providers) |
$0 copayment |
0% coinsurance |
Routine Mammogram
(no referral required for in-network providers) |
$0 copayment |
0% coinsurance |
Routine Vision Exam
(no referral required for in-network physician) |
$25 copayment
(1 visit every 24 months) |
0% coinsurance |
Dental: Preventive and Diagnostic
(no referral required for in-network dentist) |
$25 copayment
(1 visit every 6 months) |
0% coinsurance |
|
Physician Services |
|
PCP Visits |
$20 copayment |
0% coinsurance |
|
Specialist Visits |
$25 copayment |
0% coinsurance |
|
Inpatient Medical Care |
$0 copayment |
10% coinsurance |
|
Outpatient Surgical Care |
$0 copayment |
10% coinsurance |
|
Allergy Services |
|
Specialist Visits |
$25 copayment |
0% coinsurance |
|
Injections |
$0 copayment |
0% coinsurance |
|
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 |
|
Urgent Care Center/ER After-hours Clinic Visit |
$100 copayment (waived if admitted to same hospital) |
0% coinsurance |
|
Ambulance (Land or Air) |
$1000 max per year
(Limitation applies to transport charges only.) |
$0 copayment |
0% coinsurance |
|
Home Nurse Visits |
|
(120 visits per year) |
$0 copayment |
0% coinsurance |
|
Home Infusion IV, Drugs/Solutions |
|
|
$0 copayment |
10% coinsurance |
|
Physical, Occupational, Speech Therapy and Chiropractic Services |
|
(15 visits per member per therapy per year) |
$0 copayment |
20% coinsurance |
|
Inpatient Hospital |
|
(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) |
$250 copayment per admission (maximum: 3 copays per year, per person) |
10% coinsurance |
|
Maternity Services |
|
Initial Physician Visit |
$20 copayment |
0% coinsurance |
|
OB Services |
$0 copayment |
10% coinsurance |
|
Hospital Services (facility fee) |
$250 copayment per admission |
10% coinsurance |
|
Inpatient Physician Services |
$0 copayment |
10% coinsurance |
|
Outpatient Diagnostic Testing (lab and X-ray) |
$0 copayment |
10% coinsurance |
|
Transplants |
|
(specific transplants covered subject to contract-year limits when authorized in
advance by Health Advantage) |
$250 inpatient hospital copayment |
0% coinsurance |
|
Durable Medical Equipment |
|
($10,000 maximum per year) |
0% copayment |
20% coinsurance |
|
Prosthetics |
|
($15,000 maximum per year) |
0% copayment |
20% coinsurance |
|
TMJ |
|
($500 lifetime maximum) |
$25 copayment |
0% coinsurance |
|
Mental Health/Substance Abuse |
|
|
Not covered by Health Advantage. Benefits administered and claims paid by CORPHEALTH. Call 1-866-378-1645 for coverage information. |
|
Prescription Drugs |
|
|
Not covered by Arkansas Blue Cross and Blue Shield. Benefits administered and claims
paid by National Medical Health Card RX. Access NMHDRX at www.nmhcrx.com. |
**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.