Ph: (229)249-0940 • Fax: (229)249-9840 • Toll Free: (877)949-0940
| Preventive Services | |
|---|---|
| You Pay: | |
Preventive care services for adults age 19 and older including the preventive services recommended by the U.S. Preventive Services Taskforce. Services include but are not limited to:
|
Nothing for covered services |
Routine immunizations for adults age 19 and older [as licensed by the U.S. Food and Drug Administration (FDA)], not limited to:
|
Nothing for covered services |
| Preventive care services for children up to age 19, including preventive services recommended under the Affordable Care Act and the American Academy of Pediatrics. These services include but are not limited to visits or exams for preventive care, routine hearing and vision screenings, laboratory tests, immunizations, and nutritional counseling. | Nothing for covered services |
| FIVESTAR Telehealth Mobile Clinic | |
| Office visits, Medication, Laboratory testing, EKG, Radiology (Preferred Hospital only) | Nothing |
| Telehealth Primary Care and Mental Health/Substance Abuse | |
| Office visits | $15 (telehealth) office visit Copayment |
| Professional Provider’s Care | |
| Office visits | $25 office visit Copayment for Primary Care Provider (PCP)
$50 office visit Copayment for Specialist |
| X-ray, lab and diagnostic testing | $800 Deductible
20% Coinsurance |
| Routine exams and other preventive care services | Nothing for covered services |
| Outpatient/Inpatient Consultations | $800 Deductible
20% Coinsurance |
| Surgical care | $800 Deductible
20% Coinsurance |
| Medical Emergency | |
| Emergency care - Facility | $200 Copayment for Emergency Department visit |
| Emergency care - Professional | $800 Deductible
20% Coinsurance |
| Urgent care | $50 Copayment for urgent care center |
| Hospital/Facility Care | |
| Inpatient care | $800 Deductible
20% Coinsurance |
| Outpatient care | $800 Deductible
20% Coinsurance |
| Maternity Care | |
| Prenatal and postpartum office visits | $25 Copayment |
| Obstetrical care performed by a physician or nurse midwife, such as prenatal and postpartum testing (including ultrasound, lab and diagnostic tests), and delivery | $800 Deductible
20% Coinsurance |
| Inpatient hospital
Precertification is not required. Note: you may stay in the hospital for up to 48 hours after a regular delivery and 96 hours after a c-section. We will cover a longer stay if medically necessary; precertification is required for any inpatient stay beyond these time frames. |
$800 Deductible
20% Coinsurance |
| Mental Health and Substance Abuse | |
| Inpatient Hospital/Facility | $800 Deductible
20% Coinsurance |
| Outpatient Hospital/Facility Care | $800 Deductible
20% Coinsurance |
| Office visits | $25 office visit Copayment |
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