HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (3)IN -NETWORK
OUT -OF -NETWORK
6. LIFETIME OR BENEFIT MAXIMUM
$2,000,000 maximum applies to in-
$2,000,000 maximum applies to
PAID BY THE PLAN FOR ALL CARE
and out -of -network combined. $1,000
in- and out -of -network
maximum for charges related to
combined $1,000 maximum
Temporomandibular Joint Disorder
for charges related to
(TMJ).
Temporomandibular Joint
Disorder (TMJ).
7. COVERED PROVIDERS
$3,400 physicians and 58 hospitals in
All providers licensed or
Colorado. See provider directory for
certified to provide covered
complete list.
benefits.
8. ROUTINE MEDICAL OFFICE VISITS
$10 copayment per visit.
70%
9. PREVENTIVE CARE
a) Children's services
$10 copayment per visit. Well-
Well-baby/Well-child care up
baby/Well-child care up to age 13.
to age 13, no deductible 70%.
b) Adults' services
$10 copayment per visit; up to $150 in
Not covered.
any 12 month period for individuals
age 13 and older.
10. MATERNITY
a) Prenatal care
$10 copayment per pregnancy.
70%
b) Delivery & inpatient well baby care
90% when preauthorization is
70% when preauthorization is
obtained, $250 additional deductible
obtained, $250 additional
when not preauthorized.
deductible when not
preauthorized.
11. PRESCRIPTION DRUGS
$5 for generic, $10 for brand -name.
70%. Quantity not in excess of
Level of coverage and restrictions on
Quantity not in excess of a 34 day supply.
a 34 day supply. A 90-day
prescriptions
A 90-day supply of maintenance
supply of maintenance
medications are available through a mail-
medications are available
order prescription pharmacy. One
through a mail-order
copayment for each 30-day supply up to a
prescription pharmacy. One
maximum of two copayments apply to
copayment for each 30-day
maintenance medications obtained
supply up to a maximum of two
through mail-order. Prepackaged units
copayments apply to main -
dispensed through a mail-order
tenance medications obtained
prescription pharmacy will have two
through mail-order.
copayments apply for up to three pre-
Prepackaged units dispensed
packaged units. For more information on
through a mail-order pre -
the mail-order prescription drug program,
scription pharmacy will have
or for information on drugs on our
two copayments apply for up to
approved list, call Customer Service at 1-
three pre -packaged units. For
800-255-1180.
more information on the mail-
order prescription drug
program, or for information on
drugs on our approved list, call
Customer Service at 1-800-255-
1180.
12. INPATIENT HOSPITAL
90% when preauthorization is obtained,
70% when preauthorization is
$250 additional deductible when not
obtained, $250 additional
preauthorized.
deductible when not
preauthorized.
13. OUTPATIENT/AMBULATORY
90% when preauthorization is obtained,
70% when preauthorization
SURGERY
$250 additional deductible when not
is obtained, $250 additional
preauthorized.
deductible when not
preauthorized.
14. LABORATORY & X-RAY
90%
70%