Well-Care HMO Health Plans Group Products| I. Physician Services | -- -- |
| A. Primary Care Physician, Included but not limited to: routine office visits/evaluations pediatric and well baby care. |
$15 |
| B. Consultations, diagnosis and treatment by specialist. | $15 |
| C. Laboratory, X-ray or other diagnostic testing when done in an outpatient facility and authorized by Well Care HMO, Inc. | No Charge |
| II. Hospital Services | ---- |
| A. Inpatient care at participating hospitals including all general services and semi-private room. | $250/Day (Max. Of $500) |
| B. Outpatient surgical care performed in a hospital or participating ambulatory surgery. | $100/Visit |
| C. Outpatient non-surgical care such as x-rays, lab, etc. | No Charge |
| III. Emergency Services* | ---- |
| A. Emergency care in Primary Care Physician's office | $15 |
| B. Emergency care through a participating hospital E.R. |
$100/Visit (Waived if admitted) |
| IV. Special Services* | ---- |
| A. Ambulance | $50/Trip |
| B. Durable medical equipment | No Charge |
| C. Home Health Care | $10/Visit (Max. 60 Visits per calendar year) |
| D. Rehabilatative Therapy | $20/Visit (Max. 60 Visits per calendar year |
| E. Hospice | No Charge |
| F. Skilled Nursing Facility | No Charge |
G. Sterilization:
|
No Charge $200 |
| H. Contraceptive Appliances | $100 |
| I. Spine and back disorder | $10 CoPay |
| V. Mental Health & Nervous Disorder * | ---- |
| A. Inpatient care for crisis intervention | $100 CoPay per admission (Max. 30 days per calendar year) |
| B. Outpatient visits | $10 CoPay/group therapy $20 CoPay/individual therapy (Max. 30 days per calendar year) |
C. Alcohol and drug benefits
|
$100 CoPay per admission $35 CoPay |
| VI. Maternity Services | ---- |
| Pre and Post Natal Care | Same as specialist & hosital CoPay |
| VII. Prescription Drugs* | $10 CoPay |
| VIII. Organ & Tissue Transplant Benefit | No Lifetime Maximum |
| IX. Lifetime Maximum | Unlimited |
| X. Maximum member co-payment aggregate out-of-pocket limit for any calendar year is equal to: | $1500 Single $3000 Family |
* Limitations:
III. Emergency Services:
IV. Special Services:
V. Mental Health and Nervous Disorder: VII. Prescription Drugs:
PCP must be notified either prior to or after receiving emergency health care. Member MUST follow PCP's instructions.
A. Ambulance:: If medically necessary. CoPay waived if transfer between facilities. DME - limited to cane/crutches,walkers, hospital beds, commode chairs, bedpans, urinals, decubitus care equipment, ostomy and urinary products, LSO and TLSO braces, traction equipment and standard wheelchairs ONLY.
F. Skilled Nursing Facility:
Up to 100 days lifetime benefits in lieu of continued hospitalization.
A. Inpatient care for crisis intervention & B. Outpatient visits:
$30,000 lifetime max. Applies to all mental and nervous disorders, inpatient and outpatient care combined.
C. Alcohol and Drug Benefits inpatient outpatient:
Lifetime max. $4,000 inpatient and outpatient combined.
Covered person must pay 100% of the cost difference if brand name used when a generic substitute is available.