| Network |
See Provider |
See Provider |
| Application |
Distinct Advantage HMO Option 4 Application |
Distinct Advantage HMO Option 4 Application |
| Brochure |
Distinct Advantage HMO Option 4 Brochure |
Distinct Advantage HMO Option 4 Brochure |
| Copay |
Primary Care Physician- $25 per visit Specialist- $50 per visit with referral |
Primary Care Physician- $25 per visit Specialist- $50 per visit with referral |
| Office Visit |
Primary Care Physician- $25 per visit Specialist- $50 per visit with referral |
Primary Care Physician- $25 per visit Specialist- $50 per visit with referral |
| Deductible |
N/A |
N/A |
| Coinsurance |
N/A |
N/A |
| Coinsurance Limit |
N/A |
N/A |
| Out-of-Pocket Maximum |
Annual Copayment Maximum: $5,000 per Member per Calendar Year and $10,000 per Family per Calendar Year |
Annual Copayment Maximum: $5,000 per Member per Calendar Year and $10,000 per Family per Calendar Year |
| Lifetime Maximum |
$1,000,000 |
$1,000,000 |
| Prescription Drugs |
Retail Pharmacy:- Preferred Generic Covered Drug - $10 copayment per Retail Plan Pharmacy up to 30 day Therapeutic Supply
- Preferred Brand Covered Drug without Generic Covered Drug equivalent - $35 copayment up to Retail Plan Pharmacy up to 30 day Therapeutic Supply
- Preferred Brand Name Covered Drugs with a Generic Equivalent - $10 plus the difference between the EME of the Generic Covered Drug and the EME of the Brand Name Covered Drug up to a 30 day Therapeutic Supply at a Plan Pharmacy (Eligible Medical Expense - means the maximum amount the plan will pay for a Covered Service or Covered Drug in accordance with the Plan Reimbursement Schedule. Insured is responsible for all amounts exceeding the Plans EME payment when charges are billed by NonPlan Providers. Charges in excess of maximum benefit payments and EME may be substantial.)
- Non-Preferred Generic or Brand Name Covered Drugs - $60 per Retail Plan Pharmacy up to a 30 day Therapeutic Supply
Mail Order Pharmacy:- Preferred Maintenance Generic Covered Drug - $20 copayment per Mail Order Plan Pharmacy, up to a 90-day Maintenance Supply
- Preferred Maintenance Brand Name Covered Drug - $70 copayment per Mail Order Plan Provider, up to a 90-day Maintenance Supply
- Insured pays two (2) copays of the applicable Drug Fees as outlined for up to a 90 day Maintenance Supply for Preferred Generic or Brand Name Covered Drugs. NonPreferred Generic or Brand are NOT available via Mail Order Pharmacy. NonMaintenance Drugs are NOT available via Mail Order Pharmacy.
Benefits for Non-Preferred Self-Injectible and Orphan Covered Drugs as defined are payable at 50% of EME |
Retail Pharmacy:- Preferred Generic Covered Drug - $10 copayment per Retail Plan Pharmacy up to 30 day Therapeutic Supply
- Preferred Brand Covered Drug without Generic Covered Drug equivalent - $35 copayment up to Retail Plan Pharmacy up to 30 day Therapeutic Supply
- Preferred Brand Name Covered Drugs with a Generic Equivalent - $10 plus the difference between the EME of the Generic Covered Drug and the EME of the Brand Name Covered Drug up to a 30 day Therapeutic Supply at a Plan Pharmacy (Eligible Medical Expense - means the maximum amount the plan will pay for a Covered Service or Covered Drug in accordance with the Plan Reimbursement Schedule. Insured is responsible for all amounts exceeding the Plans EME payment when charges are billed by NonPlan Providers. Charges in excess of maximum benefit payments and EME may be substantial.)
- Non-Preferred Generic or Brand Name Covered Drugs - $60 per Retail Plan Pharmacy up to a 30 day Therapeutic Supply
Mail Order Pharmacy:- Preferred Maintenance Generic Covered Drug - $20 copayment per Mail Order Plan Pharmacy, up to a 90-day Maintenance Supply
- Preferred Maintenance Brand Name Covered Drug - $70 copayment per Mail Order Plan Provider, up to a 90-day Maintenance Supply
- Insured pays two (2) copays of the applicable Drug Fees as outlined for up to a 90 day Maintenance Supply for Preferred Generic or Brand Name Covered Drugs. NonPreferred Generic or Brand are NOT available via Mail Order Pharmacy. NonMaintenance Drugs are NOT available via Mail Order Pharmacy.
Benefits for Non-Preferred Self-Injectible and Orphan Covered Drugs as defined are payable at 50% of EME |
| Emergency Room |
Within Service Area: Urgent Care: - Southwest Medical Associates (SMA) Plan Provider - $45 per visit
- Other Plan Provider - $50 per visit
- Non Plan Provider - $60 per visit
Physician's Services in ER:- Plan Provider - $25 per visit
- Nonplan Provider - $75 per visit
Emergency Room:- Plan Provider - $75 per visit, waived if admitted
- Nonplan Provider - $150 per visit, not waived if admitted
Lab and X-Ray:- Plan Provider - $15 per visit
- Non-Plan Provider - $30 visit
Hospital Admission - Emergency Stabilization (Applies until patient is stabilized and safe for transfer as determined by the attending Physician). $300 per day not to exceed $900 per admission. No benefits are payable for treatment received in a Hospital emergency room or other emergency facility for a condition other than an Emergency Service as defined in the AOC. |
Outside the Service Area: Urgent Care- $60 per visit Physician's Services in ER - $75 per visit Emergency Room - $150 per visit, not waived if admitted Lab and X-Ray - $30 per visit Hospital Admission - Emergency Stabilization (Applies until patient is stabilized and safe for transfer as determined by the attending Physician). $300 per day not to exceed $900 per admission. No benefits are payable for treatment received in a Hospital emergency room or other emergency facility for a condition other than an Emergency Service as defined in the AOC. |
| Adult Preventative Care |
$10 per visit Limited to maximum benefit of $250 per Member per Calendar Year. Benefits for Pap smears and mammography will not be subject to the Calendar Year maximum benefit amount. Refer to your Agreement of Coverage for applicable age and frequency limitations. |
$10 per visit. Limited to maximum benefit of $250 per Member per Calendar Year. Benefits for Pap smears and mammography will not be subject to the Calendar Year maximum benefit amount. Refer to your AOC for applicable age and frequency limitations. |
| Child Preventative Care |
$10 per visit. Limited to maximum benefit of $250 per Member per Calendar Year. Benefits for Pap smears and mammography will not be subject to the Calendar Year maximum benefit amount. Refer to your AOC for applicable age and frequency limitations. |
$10 per visit. Limited to maximum benefit of $250 per Member per Calendar Year. Benefits for Pap smears and mammography will not be subject to the Calendar Year maximum benefit amount. Refer to your AOC for applicable age and frequency limitations. |
| Lab / X-Ray |
Routine outpatient lab/x-ray- $15 per visit Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician's office or at an independent laboratory or radiological facility. |
Routine outpatient lab/x-ray- $15 per visit Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician's office or at an independent laboratory or radiological facility. |
| Maternity |
This plan does not include maternity. |
This plan does not include maternity. |
| Physical Therapy |
Short term rehabilitation has limitations, please see Schedule of Benefits. |
Short term rehabilitation has limitations, please see Schedule of Benefits. |
| Skilled Nursing |
$300 per admission. Subject to maximum benefit. Limited to thirty (30) days per Member per Calendar Year. |
$300 per admission. Subject to maximum benefit. Limited to thirty (30) days per Member per Calendar Year. |
| Home Health Care |
Refer to your outpatient Prescription Drug Benefit Rider, if applicable, for your outpatient self-injectable covered drug benefit. Physician House Calls- $50 per visit Home Care Services- $50 per visit Private Duty Nurse- $25 per visit Limited to thirty (30) visits per Member per Calendar Year. |
Refer to your outpatient Prescription Drug Benefit Rider, if applicable, for your outpatient self-injectable covered drug benefit. Physician House Calls- $50 per visit Home Care Services- $50 per visit Private Duty Nurse- $25 per visit Limited to thirty (30) visits per Member per Calendar Year. |
| Mental Health |
Inpatient Hospital Facility - limited to thirty (30) days per Member per Calendar Year- $300 per day not to exceed $900 per admission. Subject to maximum benefit
Outpatient Treatment:- Group Therapy - limited to twenty (20) visits per Member per Year - $25 per visit. Subject to maximum benefit.
- Individual, Family and Partial Care Therapy - limited to twenty (20) visits per Member per Calendar Year - $25 per visit. Subject to maximum benefit.
Benefit maximum does not apply to visits for medication management. Partial care refers to a coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. |
Inpatient Hospital Facility - limited to thirty (30) days per Member per Calendar Year- $300 per day not to exceed $900 per admission. Subject to maximum benefit
Outpatient Treatment:- Group Therapy - limited to twenty (20) visits per Member per Year - $25 per visit. Subject to maximum benefit.
- Individual, Family and Partial Care Therapy - limited to twenty (20) visits per Member per Calendar Year - $25 per visit. Subject to maximum benefit.
Benefit maximum does not apply to visits for medication management. Partial care refers to a coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. |
| Hospital Care |
Inpatient Hospital Facility for Elective and emergency post-stabilization admission - $300 per day not to exceed $900 per admission. Outpatient Hospital Facility and Ambulatory Surgical Facility Services - $200 per admission. |
Inpatient Hospital Facility for Elective and emergency post-stabilization admission - $300 per day not to exceed $900 per admission. Outpatient Hospital Facility and Ambulatory Surgical Facility Services - $200 per admission. |
| Optional Benefits |
Distinct Advantage HMO Option 4 |
Distinct Advantage HMO Option 4 |
