Well-Care Platinum Plus
| I. Physician Services | -- -- |
| A. Primary Care Physician, Included but not limited to: routine office visits/evaluations pediatric and well baby care. |
$5 |
| B. Consultations, diagnosis and treatment by specialist. | $5 |
| C. Laboratory, X-ray or other diagnostic testing when done in an outpatient facility and authorized by Well Care HMO, Inc. | No Charge |
| D. Immunizations | No Charge |
| E. Radiation Therapy | No Charge |
| F. CT Scan, MRI, Mammogram, Ultrasound, Nuclear Medicine | No Charge |
| II. Hospital Services | ---- |
| A. Inpatient care at participating hospitals including all general services and semi-private room. | $100/Day (First Two Days) |
| B. Outpatient surgical care performed in a hospital or participating ambulatory surgery. | No Charge |
| C. Outpatient non-emergency care services | No Charge |
| D. In-hospital physician services | No Charge |
| III. Emergency Services* | ---- |
| A. In-Network Physician | No Charge |
| B. Non-Network Physician | $50 CoPay |
| C. Emergency Room | $50 CoPay |
| IV. Special Services* | ---- |
| A. Ambulance | No Charge |
| B. Hearing Exams | $10 CoPay |
| C. Home Health Care | No Charge |
| D. Short Term Rehabilatative Therapy | No Charge (Max. 60 Days per Condition) |
| E. Skilled Nursing Facility | No Charge (30 days per CY maximum) |
| V. Mental Health & Nervous Disorder * | ---- |
| A. Inpatient | $100 CoPay first 2 days (Max. 10 days per calendar year) |
| B. Outpatient visits | No Charge (Max. 20 days per calendar year) |
C. Alcohol and Substance Abuse
|
$100 CoPay for first 2 days (10 visits per calendar year) No Charge (30 visits per calendar year) |
| VI. Optional Maternity Services | ---- |
| A. Physician Services | $5 CoPay |
| B. Hospital Services | $100/day CoPay first 2 days |
| VII. Prescription Drugs* | ---- |
| Generic (for 31 day supply) | $ 5 CoPay |
| Non-generic (for 31 day supply) | $10 CoPay |
| VIII. Vision | ---- |
| Vision exams/eye glasses | $10 CoPay |
| IX. Dental Services | ---- |
| A. Cleaning & Exams | No Charge |
| B. X-rays | No Charge |
| C. Extractions (up to 2 non-surgical) | No Charge |
| D. Fillings* (amalgam 1 surface) *Other services are available at discounted prices. |
No Charge |
* 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.