Parrish Medical Center Self-Funded HMO Plan 11F Administered by Florida Health Care Plans (FHCP) Schedule of Benefits Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your benefits can be found. This is an HMO Plan. providers are not covered except in Emergency situations. is the which includes Parrish Health Network providers, Parrish Cancer Center, Dr. Frometa, Doctor on Demand, Mayo, Nemours and other providers. is the which includes select Florida Health Care Plans (FHCP) providers not included in PPN in all FHCP service areas, including LabCorp and Halifax Medical Center. You should always verify a Provider s participation status prior to receiving Health Care Services. To verify a Provider s specialty or participation status, you may search for the provider in the FHCP Member Portal. You may also contact the FHCP Member Services Department at 1-877-615-4022 (TRS Relay 711) or access the most recent Provider directory on FHCP s website at Find a Doctor / Facility. References to the Calendar Year Deductible are abbreviated in the chart below as "DED". Your benefits accumulate toward the satisfaction of Deductibles, Out-of-Pocket Maximums, and any applicable benefit maximums based on your Benefit Period unless indicated otherwise within this Schedule of Benefits. Your Benefit Period... 01/01 12/31 Deductible, Coinsurance and Out-of-Pocket Maximums Deductible (DED)* Per Person per Benefit Period $800 $900 N/A Per Family per Benefit Period $1,600 $1,800 N/A Out-of-Pocket Maximums** Per Person per Benefit Period $3,500 $4,850 N/A Per Family per Benefit Period $7,000 $9,700 N/A and Deductibles do not cross accumulate. and Out-of-Pocket maximums do not cross accumulate. 1
What applies to out-of-pocket maximums? What does not apply to out-of-pocket maximums? DED Coinsurance Copayments Prescription Drug Cost Share Amounts Health Care This Plan Doesn t Cover Office No Show Charges Premiums Charges in Excess of the Allowed Amount Penalties for Failure to Obtain Pre- Authorization for services Important information affecting the amount you will pay: As you review the Cost Share amounts in the following charts, please remember: Review this Schedule of Benefits carefully. Amounts listed in this schedule are the amounts you pay for Covered Services you receive. This plan uses a tiered network of providers. You pay the least if you use a provider in the Parrish Preferred Network. You pay more if you use a provider in the Parrish Select Network. For a list of network providers, you may search for the provider in the FHCP Member Portal, in the online provider directory or you may call FHCP Member Services at 1-877-615-4022 TRS Relay 711. This plan will pay some or all of the costs to see a specialist. Most covered services requiring a specialist will be paid, but only if you have a referral before you see the specialist. If you have a question on which specialties require a referral, refer to Sections 9 & 10 of the Summary of Plan Description or call FHCP Member Services at 1-877-615-4022 (TRS Relay 711). Your Cost Share amounts will vary depending upon the Provider you choose, the type of Services you receive, and the setting in which the Services are rendered. Payment for Covered Services is based on our Allowed Amount and may be less than the amount the Provider bills for such Service. You must pay all of the costs up to the deductible amount for those services subject to the Calendar Year Deductible before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Any services subject to deductible will have a DED in the cost sharing charts below. If a Copayment is listed in the charts that follow, the Copayment applies per visit. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family outof-pocket limit has been met. 2
Office Services A Primary Care Physician is a Physician whose primary specialty is one of the following: Family Practice, General Practice, Internal Medicine, and Pediatrics. Medical Home / Primary Care Office (PCP) visits rendered by Family Physicians and Other health care professionals licensed to perform such services Specialist Office Visits (Spec) rendered by Physicians and Other health care professionals licensed to perform such services $20 $50 $45 $100 Maternity Visits initial office visit rendered by Family Physicians and Other health care professionals licensed to perform such Services $20 PCP $45 - Spec $50 PCP $100 - Spec Office Ancillary e.g. lab, x-ray, surgery, injections, supplies. Note: Inclusive of Office visit copay. $0 $50 PCP $100 - Spec Allergy Injections & Testing rendered by Primary Care Office $20 $50 Specialist Office $45 $100 Diabetic Education / Training / Counseling rendered in physician s office or by an in network provider $0 $0 Physical, Speech, Occupational, Cognitive Therapy Services rendered in physician s office or an outpatient setting. Limited to 30 visits per Calendar Year maximum. $20 PCP $45 - Spec $50 PCP $100 - Spec Cardiac and Pulmonary Rehabilitation rendered in physician s office or an outpatient setting. Limited to 30 visits per Calendar Year maximum. $20 PCP $45 - Spec $50 PCP $100 - Spec Chiropractic Care (Spinal Manipulations) rendered in physician s office or an outpatient setting. Limited to 20 visits per Calendar Year maximum. $45 $45 Chemotherapy/I.V Therapy rendered in physician s office or an outpatient setting DED + 10% 3
Chemotherapy/Radiation Therapy rendered in physician s office or an outpatient setting DED + 10% Nutritional Counseling rendered by Physicians and Other health care professionals licensed to perform such services in an office setting. Depo Provera (medically necessary) $25 $25 $20 PCP $45 - Spec $50 PCP $100 - Spec 4
Preventive Health Services Tier 3 Adult Wellness Services rendered by Family Physicians $0 $0 Other health care professionals licensed to perform such Services $0 $0 Adult Well Woman Services rendered by Family Physicians $0 $0 Other health care professionals licensed to perform such Services $0 $0 Child Health Supervision Services Rendered by Family Physicians $0 $0 Other health care professionals licensed to perform such Services $0 $0 Screening Mammograms $0 $0 Screening Colonoscopy $0 $0 Birth Control Devices $0 $0 Depo Provera (routine) $0 $0 Sterilization female, elective $0 $0 5
Outpatient Diagnostic Services Independent Lab $0 Independent Diagnostic Testing Facility Imaging Services (CT & MRI) $50 Imaging Services (PET Scans & Nuclear studies etc.) DED + 10% Diagnostic Testing (X-ray & Ultrasound) $0 Outpatient Hospital Facility See Hospital Services Outpatient Emergency and Urgent Care Services Ambulance Services Emergency Room Visits See Hospital Services Emergency Room Visits Urgent Care Center $20 Onsite $25 Medfast & Restore $20 Onsite $25 Medfast & Restore Outpatient Surgical Services Ambulatory Surgical Center Facility (per visit) DED + 10% $500 copayment then Physician Services DED + 10% Outpatient Hospital Facility See Hospital Services Outpatient 6
Hospital Services Inpatient Facility Services DED + 10% $1,000 copayment then Physician services DED + 10% Anesthesia DED + 10% Pre-admission Testing DED + 10% Outpatient Surgical (per procedure) DED + 10% $500 copayment then Physician Services DED + 10% Anesthesia DED + 10% Imaging Services (CT/CAT Scans & MRI) $50 Imaging Services (PET Scans, Nuclear Studies etc.) DED + 10% Diagnostic Testing (X-ray, Ultrasound & Lab) $0 Emergency Room Visits Facility (per visit) (waived if admitted) $200 $200 $200 Physician Services $0 $0 $0 23 Hour Observation DED + 10% $500 copayment then 7
Behavioral Health Services Outpatient Mental Health and Substance Dependency Treatment Services Emergency Room (per visit) (waived if admitted) $200 $200 $200 Physician Services at ER $0 $0 $0 Outpatient Hospital / Treatment Facility DED + 10% Physician Services at Outpatient Hospital / Treatment Facility DED + 10% All other locations DED + 10% DED +30% Office Visit MHP/Specialist* $20 / $45 $50 / $100 Marriage Counseling MHP/Specialist* $20 / $45 $50 / $100 Bereavement Counseling MHP/Specialist* $20 / $45 $50 / $100 Group Counseling Sessions MHP/Specialist* $10 / $22.50 $25 / $50 Telemedicine (video visit) $45 A Mental Health Professional (MHP) means a person properly licensed to treat mental health problems pursuant to the Florida Statutes, or similar applicable laws of another state. This professional may be a clinical social worker, mental health counselor or marriage and family therapist. A Specialist means a Physician who limits practice to certain types of diseases like a Psychiatrist or Psychologist. Inpatient Hospital/Acute Care Center Facility Services DED + 10% $1,000 Copayment then Physician Services at Hospital/Acute Care Center DED + 10% Residential/Rehabilitation Center 60 days combined Calendar Year maximum includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities Facility Services DED + 10% $1,000 Copayment then Physicians services at Residential/Rehabilitation Center DED + 10% 8
Other Covered Services Telemedicine Visits (Video visits) rendered by Family Physicians and Other health care professionals licensed to perform such Services. $15 See Behavioral Health Outpatient for cost sharing applicable to Mental Health visits. Colonoscopy Services Diagnostic (non-routine) $0 $0 Sleep Studies DED + 10% Home Health Care Limited to 60 days per Calendar Year maximum - inclusive of *outpatient private duty nursing maximum Outpatient Private Duty Nursing Limited to 60 days per Calendar Year maximum* DED + 10% DED +30% DED + 10% DED +30% Hospice Care DED + 10% DED +30% Outpatient Rehabilitation Facility 60 days combined Calendar Year maximum includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities DED + 10% $1,000 Copayment then Skilled Nursing Facility 60 days combined Calendar Year maximum includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities DED + 10% $1,000 Copayment then Prosthetics DED + 10% Orthotics DED + 10% Durable Medical Equipment DED + 10% Allergy Serum 10%, deductible waived 30%, deductible waived Therapeutic Injections DED + 10% DED +30% RSV Injections DED + 10% DED +30% Dialysis Treatment rendered in outpatient facility DED + 10% 9
Wig After Chemotherapy DED + 0% Breast Pumps Limited to 1 pump per birth. Coverage provided for the rental or purchase of a manual or double electric pump. Hospital grade pumps are not covered. $0 $0 Lactation Counseling $0 $0 Diabetic Pump & Supplies DED + 10% Other Diabetic Supplies Glucometer $0 50 Test Strips / Sensors (per box) $10 Copay Lancets (per box) $10 Copay Hearing Aids $1,000 Lifetime Maximum Allowance $0 Open Access to All Providers Mastectomy Bras Limited to 4 post-mastectomy bras. Medically Necessary post-mastectomy bras will be limited to 2-4 every 12 months Infertility Benefits Office visit & Testing Includes: care, supplies and services up to diagnosis of infertility $0 $45 $100 Sterilization - male DED + 10% Organ Transplant s Facility 100% after $1,000 100% after $1,000 per admission per admission copayment, copayment, for COE for COE facilities, otherwise, facilities, otherwise, 70% 90% after $1,000 per after $1,000 per admission copayment and admission copayment and deductible. deductible. Organ Transplant s Physician inpatient / outpatient visits 100% for treatment at COE facilities, otherwise, 90% after deductible. 100% for treatment at COE facilities, otherwise, 70% after deductible. Lifetime Travel Maximum $10,000 per Transplant only payable if using COE facility $0 10
Benefit Maximums Combined Limit and Home Health Care Outpatient Private Duty Nurse included with Home Health Care Nutritional Counseling combined maximum limit for outpatient and office setting Calendar Year Maximum 60 visits 60 visits* 3 visits Occupational Therapy, Speech Therapy, Physical Therapy, Cognitive Therapy combined maximum limit 30 visits Cardiac Rehabilitation and Pulmonary Rehabilitation Therapy combined maximum limit 30 visits Chiropractic Care (Spinal Manipulation) 20 visits Skilled Nursing Facility / Rehabilitation Hospital / Sub-Acute Facilities combined maximum limit Transplant Services (Lifetime Travel Maximum) Lodging and Transportation for Transplant Recipient and Companion (per transplant) (only payable if using COE facility) 60 days $10,000 11
Pharmacy & Prescription Drug Program Schedule of Benefits You should carefully review this Pharmacy Program Schedule of Benefits. To verify if a Pharmacy is a Participating Pharmacy, you may access the Pharmacy Program Provider Directory on FHCP s website at Find a Pharmacy or call the FHCP Member Services Department at 1-877-615-4022 (TRS Relay 711). FHCP Pharmacy Participating Walgreens Pharmacies Pharmacy Deductible per Calendar Year Per Individual $0 Family Maximum $0 Maximum Out-of-Pocket per Calendar Year Per Individual $2,000 Family Maximum $4,000 Preventive Drugs purchased at: Retail Pharmacy For up to a One-Month Supply $0 Mail Order Pharmacy For up to a Three-Month Supply $0 Preferred Generic Prescription Drugs purchased at: Retail Pharmacy For up to a One-Month Supply $0 The greater of 20% coinsurance or $7 copayment Mail Order Pharmacy For up to a Three-Month Supply $0 Non-Preferred Generic Prescription Drugs purchased at: Retail Pharmacy For up to a One-Month Supply $4 The greater of 20% coinsurance or $7 copayment Mail Order Pharmacy For up to a Three-Month Supply $8 Preferred Brand Name Prescription Drugs purchased at: Retail Pharmacy For up to a One-Month Supply $25 The greater of 30% coinsurance or $35 copayment, Mail Order Pharmacy For up to a Three-Month Supply $60 Non-Preferred Brand Name Prescription Drugs purchased at: Retail Pharmacy For up to a One-Month Supply $50 The greater of 40% coinsurance or $60 copayment Mail Order Pharmacy For up to a Three-Month Supply $125 Specialty Drugs: Preferred Specialty Drugs Non-Preferred Specialty Drugs The greater of $250 copayment or 30% coinsurance The greater of $500 copayment or 40% coinsurance
Important information affecting the amount you will pay: This plan uses a pharmacy network. You pay the least if you use an FHCP pharmacy. You pay more if you use a Walgreen s or other participating pharmacy. For a list of FHCP, Walgreens or other participating pharmacies, search the online directory at Find a Pharmacy or call FHCP Member Services at 1-877-615-4022 (TRS Relay 711). For additional savings, fill prescriptions via our mail order program. This program allows covered members taking prescription drugs to receive up to a 3-month supply for one Mail Order Copayment. Prescription drugs ordered through this program are provided by FHCP. FHCP has a Discount Medication List available online at: https://www.fhcp.com/for-members/aboutyour-care/ under the Medication Formulary section. Certain medications require prior authorization. The FHCP Prior Authorization Medication Policy and Drug List are available online at: https://www.fhcp.com/documents/medications-requiring-prior-auth.pdf Changes in the formulary can occur over time and the most up-to- date listing can always be found by viewing the Commercial Formulary online or call FHCP Member Services at 1-877-615-4022 (TRS Relay 711) to request a copy.