CO-PAYMENT BOOK Las Vegas Blvd. South Suite 107 Las Vegas, NV

Transcription

1 CO-PAYMENT BOOK 1901 Las Vegas Blvd. South Suite 107 Las Vegas, NV Revised January 2018 (Replaces Co-Payment Book dated June 2017)

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3 TABLE OF CONTENTS Culinary Health Center Preventive Physician Office Physician Office (continued) 7 Prescriptions Ambulatory Surgery Center 8 9 Therapy at an Outpatient Free Standing Facility Free-Standing Facility Free-Standing Facility (continued) Outpatient in a Hospital Outpatient in a Hospital (continued) Ambulance Emergency Room vs. Urgent Care In-Network Hospital (in-patient) Mental Health & Addictions Breast Care at a Free-Standing Facility Other Other (continued) 3

4 Type of Copay Care per Visit The yearly amount you have to pay out of your pocket for your co-pays and coinsurance is $6,350 per person or $12,700 per family. (Includes medical and prescription copays/excludes dental copays) Primary Doctor Pediatrician Urgent Care Culinary Pharmacy Same copays as The Culinary Health Center Culinary a dentist is located at: 100% of Health in the 650 North Nellis Blvd. allowable Center Dental Care network. Las Vegas, NV Refer to Dental Book for more info. $10 copay Eye Care for eye exams Immunizations for adults (Age appropriate) & children (Birth to age 18) Preventive Well Baby/Child Exams (Birth to age 21) Annual Physical Exams Nutritional Counseling Osteoporosis Screening (Women age 65 and older) Mammography (Women age 35 and older) Women s well check (Ages 21 to 64) Colonoscopy & Sigmoidoscopy (Ages 50 to 74) 100% of allowable For a complete list of preventive services covered by the Affordable Care Act please visit uspreventiveservicestaskforce. org/page/name/uspstf-a-andb-recommendations-by-date/ You can also contact the Customer Service Office at if you have any questions. 4

5 Type of Care Physician Office Copay per Visit Primary Doctor $15 Primary Doctor at the Culinary Health Center Specialist $30 In-Patient Injection IV Treatment Pulmonary Treatment Pulmonary Test Chiropractor $25 Urgent Care at the Culinary Health Center Urgent Care $40 No other information. Contact CACP at for Providers. Urgent Care at the Culinary Health Center is open 24 hours a day, 7 days a week Tip: Want to save money? Call Dr. Tomorrow at and get an appointment with a doctor the same day or within 24 hours. X-Ray/Ultrasound $30 Radiology-PET/PET CT $225 per visit Copay applies only in select physician offices. Radiology-CT/MRA/MRI $125 per visit Lab No other information. 5

6 Type of Care Copay per Visit Ophthalmologist/ Optometrist (Vision Exam) Optometrist (Vision Exam) at the Culinary Health Center $20 $10 Lenses and frames are covered under the vision category. Chemotherapy Radiation Therapy need to be provided at Comprehensive Cancer Centers of Nevada. Hearing & Speech Exam Physician Office (continued) Allergy Testing Allergy Immunotherapy Surgery in the physician s office Nerve conduction studies No other information. Dialysis Management All other physician office procedures Sleep Study performed in a doctor s office $125/ procedure 6

7 Type of Care Copay per Visit Culinary Pharmacy (Generic medications only) 100% Tip: you can save money by asking your doctor for a generic medication Contact the Culinary Pharmacy on Las Vegas Blvd. at For the Culinary Pharmacy at the Culinary Health Center call Prescriptions Tier 1 Generic medications $10 Tier 2 Formulary $20 Tier 3 Non-Formulary $35 100% after copay Tier 1, 2 & 3 medications available at retail pharmacies. For a complete list of retail pharmacies included in the Network, contact OptumRx at Specialty Exception Prescriptions 25% of allowable 75% of allowable Prior Authorization (approval) is required. Mail Order $10, $20, or $35 100% after copay With one copay, you can get a 60-day supply. Ambulatory Surgery Center Surgery $150 No other information. 7

8 Type of Care Therapy at an Outpatient Free Standing Facility (Not at a hospital) Free-Standing Facility (Not at a hospital) Copay per Visit Physical Therapy Occupational and Speech Therapy Applied Behavior Analysis (ABA) Therapy $20 $10 per day of treatment, regardless of the number of hours of treatment or the number of ABA therapy providers that see the eligible dependent during the day Lab X-Ray/Ultrasound $20 CT Scan, MRI, MRA $125 PET $175 Interventional Radiology (procedures done under anesthesia that are image-based) $150 for non-surgical Physical Therapy 30 visits per event for post-surgical Physical Therapy 30 visits per therapy Patient must have a referral from a Physician. No other information. is available for eligible dependents who are at least 2 years old and younger than 6 years old, have a valid diagnosis of autism spectrum disorder (ASD) and have a prorated mental age (PMA) of at least 11 months. Prior authorization (approval) required. must be provided by a PPO provider. The ABA Therapy is effective 1/1/17. Tip: CPL is the only lab you can use. Tip: Desert Radiologists is the only free-standing radiology facility you can use. Tip: Desert Radiologists is the only free-standing radiology facility you can use. 8

9 Type of Care Copay per Visit Dialysis Sleep Study $125 Some services require prior authorization (approval). Free-Standing Facility (Not at a hospital) (continued) Cardiac/Pulmonary Rehabilitation $30 Mammogram 30 visits annual limit Tip: Desert Radiologists is the only free-standing radiology facility you can use. There is a $75 fee for 3D Mammograms. Diagnostic Colonoscopy (for eligible persons under age 50) No other information. Lab for Hospital Based preoperative or diagnostic services only $15 X-Ray/Ultrasound $45 Some services require prior authorization (approval). Outpatient in a Hospital MRI, MRA, CT Scan $125 PET and combined PET/CT $225 Interventional Radiology and Diagnostic Radiology only performed in a hospital outpatient setting (procedures done under anesthesia that are image-based) $250 Dialysis Tip: If your doctor refers you to a hospital to have these tests, ask your doctor to send you to Desert Radiologists or CPL. Physical Therapy (after discharge from inpatient hospital admission) Occupational & Speech Therapy (after discharge from inpatient hospital admission) $30 $30 30 visits annual limit 30 visits annual limit Some services require prior authorization (approval). Cardio/Pulmonary Rehab (after discharge from inpatient hospital admission) $40 30 visits annual limit 9

10 Type of Care Outpatient in a Hospital (continued) Ambulance Emergency Room vs. Urgent Care In-Network Hospital (in-patient) Copay per Visit Outpatient Surgery $250 Diabetes Ed. Sleep Study 25% All other outpatient hospital services 25% (Not to exceed $250 per day) 75% of allowable Ground 25% 75% Air $500 per person per incident Emergency Room $350 per visit Urgent Care at the Culinary Health Center per visit Urgent Care $40 per visit Inpatient Stay Obstetrics Skilled Nursing Facility Inpatient Rehabilitation $250 $ hr observation $250 Surgery/Anesthesia 100% after copay, including all other covered ER services, as well as lab and X-ray 60 day maximum Some services require prior authorization (approval). No other information. Tip: please go to the Urgent Care for non-life threatening issues. Take a look at the Provider Directory for 24/7 Urgent Care locations. Urgent Care at the Culinary Health Center is open 24 hours a day, 7 days a week Tip: Want to save money? Call Dr. Tomorrow at and get an appointment with a doctor the same day or within 24 hours. Some services may require prior approval. Tip: Call the Customer Service Office at to make sure your hospital is in our Network. 10

11 Type of Care Copay per Visit Mental Health and Addictions Outpatient Therapy Inpatient Residential Treatment Partial Hospital Admission Intensive Outpatient Program No copay for the first 5 visits per issue/$15 copay after. $250 $150 No coinsurance 100% of allowable after copay Some services may require prior approval. Call Harmony Healthcare at for additional information. Preventive (annual mammogram) No coinsurance 100% of allowable Mammogram-Additional Views Diagnostic Mammogram $20 Breast Care at a Free- Standing Facility* Breast Ultrasound $20 Breast MRI $125 Needle-guided breast biopsy under ultrasound *Needle-guided breast biopsy under ultrasound when performed in a physician s office $20 $30 No coinsurance 100% of allowable after copay Tip: Desert Radiologists is the only free-standing radiology facility you can use. There is a $75 fee for 3D Mammograms. Needle-guided breast biopsy under CT Scan $125 11

12 Type of Care Copay per Visit Home Healthcare of 60 days per calendar year Home Infusion Therapy Hospice Diabetic Shoes $55 per pair 2 pair per calendar year No other information Mastectomy Bras $12 per item $350 per calendar year Diabetic Supplies Hearing Aids $300 every 5 years $300 every 5 years Other Compression Stockings Orthotic Shoe Inserts $22 per pair $10 per pair 3 pair per calendar year 1 pair or 2 inserts every 3 years Custom-made compression stockings require prior authorization (approval). They must be prescribed by a PPO Physician, PPO Podiatrist, PPO Orthopedic Physician or a PPO Orthotic Provider. You can get changes to your shoe inserts (called orthotic refurbishments) with no copay. You can do this any time for 3 years. Durable Medical Equipment & Medical Supplies 10% of allowable 90% of allowable Prior Authorization (approval) is required for items over $500. Enteral Nutrition 10% of allowable for supplies, including but not limited to, pumps and tubing 90% of allowable for supplies, including but not limited to, pumps and tubing The Plan pays 100% for formula and medical food Prior Authorization (approval) is required 12

13 Type of Care Copay per Visit Prosthetic & Orthotic Appliances 10% of allowable 90% of allowable Prior Authorization (approval) is required. Your eye exam is covered under your Physician Office. Other (continued) Glasses & Contact Lenses $150 every two years $150 every two years Eligible dependents under age 19 get: $150 for frames and contact lenses during any 24 month (2 year) period One pair of basic eyeglass lenses (not including upgrades or optional add-ons) during any 24 month (2 year) period Glasses following cataract surgery $150 $150 per lifetime Tip: If you have surgery on both eyes, wait until both surgeries are performed before using this. 13

14 1901 Las Vegas Blvd. South Suite 107 Las Vegas, NV facebook.com/culinaryhealthfund