| Coverage Description |
Horizon HMO $15 |
|
Primary Care Physician Copayment |
$15 |
|
Specialist Copayment |
$15 |
|
Deductible |
N/A |
|
Coinsurance |
50% for prescription drugs |
|
Maximum Out of Pocket |
N/A |
|
Lifetime Benefit Maximum |
Unlimited |
Inpatient Hospital
(Subject to preapproval) |
$150 copayment per day for a maximum of 5 days per admission; $1,500 maximum per calendar year. |
|
Ambulatory Surgical Center Facility Charges |
$15 |
|
Hospital Outpatient Facility Charges |
$15 |
|
Emergency Room Copayment |
$100 (Credited toward inpatient admission if admitted within 24 hours.) |
Biologically Based Mental Illness and Alcoholism
(Inpatient is subject to preapproval) |
Inpatient: $150 copayment per day for a
maximum of 5 days per admission;
$1,500 maximum per calendar year. |
|
Non-Biologically Based Mental Illness and Substance Abuse |
Inpatient (subject to preapproval):
100% after the hospital copayment for a maximum
of 30 days per year (1 inpatient day may be
exchanged for 2 outpatient visits).
Outpatient: 100% after the office copayment for a
maximum 20 visits per calendar year. |
|
Blood/Blood Products/Processing |
Plan pays 100%. |
|
Diagnostic X-ray/Lab |
Office visit copayment per visit. |
Durable Medical Equipment
(Subject to preapproval) |
Plan pays 100%. |
Home Health Care and Hospice Care
(Subject to preapproval) |
Unlimited days. |
|
Maternity |
$25 copayment for the initial visit;
$0 copayment thereafter. |
|
Prescription Drugs |
50% coinsurance. |
|
Preventive Care |
Office visit copayment per visit. |
Rehabilitation Centers
(Subject to preapproval) |
Subject to inpatient hospital copayment above.
Waived if immediately preceded by a
hospital inpatient stay. |
|
Speech, Physical (Subject to preapproval), Occupational and Cognitive Rehabilitation Therapies |
$15 office visit copayment per visit. |
|
Therapeutic Manipulations |
Office visit copayment per visit. Limited to 30 visits
per calendar year and 2 modalities per visit. |
