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Alternative Benefit Plan Information

Alternative Benefit Plan Information. PCP Copay: $35 Specialist Copay: $50 Diagnostic Lab & Xray: $0 Specialized Imaging & Scanning: $200 (i.e. MRI, CAT, PET) Hospitalization: $1,000 Copay/Admit Outpatient Surgery: $500 Copay Emergency Room: $200 Copay

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Alternative Benefit Plan Information

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  1. Alternative Benefit Plan Information PCP Copay: $35 Specialist Copay: $50 Diagnostic Lab & Xray: $0 Specialized Imaging & Scanning: $200 (i.e. MRI, CAT, PET) Hospitalization: $1,000 Copay/Admit Outpatient Surgery: $500 Copay Emergency Room: $200 Copay Out of Pocket Max: $2,500/$5,000 Prescription Benefits: $5/$30/$60

  2. Prescription Benefit Plan Information Generic Prescriptions on our Formulary: $5* Brand Named Prescriptions on our Formulary: $30* Generic or Brand Prescriptions NOT on our Formulary: $60* *Only a 30 day supply of medication may be obtained for one copayment Note: Certain medications have restricted quantity limits

  3. What makes us different from other carriers Direct Access(NO REFERRAL NEEDED) to contracted HMO Specialists – Member must still choose PCP FREEBasic Health Club Membership to Participating facilities through PRIME (enroll at www.primemember.com or call 877-238-6240) Discountsfor: Weight Loss Program discounts (i.e. Weight Watchers) Vision Materials & Lasik Surgery On-line Fitness and Wellness help which includes set up of a personal diet and exercise program Home & Personal Safety

  4. What makes us different from other carriers 24/7 Nurseline Disease Management Programs: Taking Charge of Diabetes Taking Charge of your Heart Health Taking Charge of Asthma Stop Smoking Pacificare.com – Look up providers E-mail customer service On-line wellness tools and discount information

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