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Health Plan Benefits and Premium Summary
Benefits coverage and premium rates apply to both individual and group members. Plan is guaranteed issue subject to cost sharing provisions in the first 92 days. You will be enrolled regardless of your medical conditions. Employee remains covered regardless of the employment status, through enrollment in the individual program. The plan has limited cost sharing provisions (co-payments). Refer to the member’s agreement for all applicable cost sharing provisions. The following co-payments apply after 92 days of enrollment in the plan. Refer to the member’s agreement for co-payments during the first 92 days. The plan has coverage exclusions as listed in the member’s agreement, including and not limited to hospitalization. Refer to the members agreement for non-covered services.
The plan premium is $50 per member per month
Preventive health screening
Annual Physical Examination $0 annual visit
Cervical cancer screen $0 (pap smear annually)
Non invasive colorectal cancer screening $0 (three stool guaics annually)
Prostate cancer screening $0 (PSA annually)
Primary care office visits for the diagnosis and treatment of illnesses or injuries
Primary Care Office Visits $0 per visit
Pediatrician Visits $0 per visit
Transportation $0 per visit
(to the network Primary Care Medical Center)
Physical Therapy $0 per treatment (office based)
Prescriptions drug coverage
Basic formulary only $4 per prescription (refer to formulary)
Comprehensive formulary Cost plus $4 (requires three days advance order and a 90 days supply order)
Laboratory testing
Coagulation Studies PT/INR $0
PTT $0
Complete Blood Count $0
White blood cell count
Red blood cell count
Platelet count
MCV
Hemoglobin/Hematocrit $0
Basic Metabolic Panel $0
Comprehensive Metabolic Panel $0
Electrolyte Panel $0
Lipid Panel $0
(LDL cholesterol, HDL cholesterol, Trig)
Liver Function Panel (AST, ALT, ALK Phos) $0
ABO Group and RH Type $0
Albumin (Alb) $0
Amylase $0
ANA w/Reflex titer $0
Antibody, RBC w/Reflex ID $0
Bilirubin,Total (Tbili) $0
C-Reactive Protein $0
CA 125 $0
Calcium (Ca) $0
Carbon Dioxide (CO2) $0
CEA $0
Chloride (CI) $0
Cholesterol, Total (Tchol) $0
Creatinine (Cr) w/e GFR $0
Ferritin $0
Folic Acid $0
Glucose, Serum (Glucose) $0
HCG, Serum, Qual (Pregnancy test) $0
HDL $0
Hemoglobin A1C $0
Hepatitis A AB, IGM $0
Hepatitis B Surface AB Qual $0
Hepatitis C Virus AB $0
HIV-1/HIV-2 SCR w/Reflexes $0
Iron, Total $0
LDH $0
Lead (B) $0
Magnesium $0
Microalbumin, Random Urine w/creat $0
Occult Blood in Feces – GUAIAC $0
Phosphorus $0
Progesterone $0
Protein,Total (TP) $0
PSA,Total $0
Rheumatoid Factor $0
RPR (Monitoring) w/Reflex Titer $0
Rubella IGG AB $0
SED Rate by MOD West $0
Testosterone, Total $0
Triglycerides (Trig) $0
TSH $0
UA (Urine Analysis), Dipstick Only $0
UA, Dipstick w/Reflex to Microscopic $0
UA, Complete (Dipstick & Microscopic) $0
UREA Nitrogen (BUN) $0
URIC Acid $0
Valproic Acid $0
Vitamin B12/Folic Acid $0
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Chemistry (continued)
HCG, Serum, Qual (Pregnancy test) $0
HDL $0
Hemoglobin A1C $0
Hepatitis A AB, IGM $0
Hepatitis B Surface AB Qual $0
Hepatitis C Virus AB $0
HIV-1/HIV-2 SCR w/Reflexes $0
Iron, Total $0
LDH $0
Lead (B) $0
Magnesium $0
Microalbumin, Random Urine w/creat $0
Occult Blood in Feces – GUAIAC $0
Phosphorus $0
Progesterone $0
Protein,Total (TP) $0
PSA,Total $0
Rheumatoid Factor $0
RPR (Monitoring) w/Reflex Titer $0
Rubella IGG AB $0
SED Rate by MOD West $0
Testosterone, Total $0
Triglycerides (Trig) $0
TSH $0
UA (Urine Analysis), Dipstick Only $0
UA, Dipstick w/Reflex to Microscopic $0
UA, Complete (Dipstick & Microscopic) $0
UREA Nitrogen (BUN) $0
URIC Acid $0
Valproic Acid $0
Vitamin B12/Folic Acid $0
Culture, Routine $0
Culture Throat $0
Culture Urine $0
Culture Stool $0
Culture Tissue $0
Culture Genital $0
Pap Smear Test $0
(Other laboratory tests are available, check with your provider)
Office based minor surgery with local anesthesia/procedures
Office based minor surgical procedures $0
Burn local treatment $0
Debridement of nail $0
Debridement of skin $0
Ear irrigation $0
Excision of skin lesion $0
Incision & drainage of abscess $0
Skin tag removal $0
Splinting- simple $0
Laceration (simple repair) $0
Cryosurgery $0
Arthrocentesis $0
Pulmonary testing and treatments
Spirometry $0
Aerosol Treatments $0
Radiology procedures
Plain X-Rays (2 views) $0
Skull
Face
Cervical
Chest
Abdomen
Pelvis
Extremities
Diagnostic Ultrasound (U/S)
U/S Aorta, Kidneys or Pancreas $0
U/S Breasts $0
U/S Gall bladder and Liver $0
U/S Kidneys $0
U/S Pelvis $0
U/S Scrotum and testicles $0
U/S Soft tissue $0
U/S Thyroid $0
Other U/S $0
Cardiovascular testing
Electrocardiogram $0
24 Hour Holter Monitor $0
Echocardiogram with Doppler $0
Carotid Arterial Imaging/Doppler $0
Extremities Vascular Imaging $0
Vaccines and office based injections
DT vaccine (tetanus, diphtheria) $0
Hepatitis B Vaccine $45
Influenza vaccine $15
PPD/tine (Tuberculosis screen) $0
TD (Tetanus vaccine) $0
Toradol injections (analgesic) $0
Solumedrol injections (corticosteroid) $0
Rocephin injection (antibiotic) $30
Vision/Hearing
Vision screening $0
Hearing screening $0
Specialists Care
Not a covered benefit, but can be arranged through American Care medical centers provider network. Refer to provider directory.
Hospitalization Coverage
Hospital service is not a covered benefit of the American Care Health Flex Plan. American Care medical centers will arrange for required hospitalizations services. For coverage of this type of service beneficiary should apply for other State approved programs.
To print out a copy of the Basic formulary, please click below:
2008 Medication Formulary
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