Description of Coverage - Deluxe Plans
Plan Name
A
B
 C
Hospital Deductible
$5,000
$5,000
 $5,000
Outpatient Services
Primary Care Physician (PCP)
$25 per visit
PCP at Contracted Plan A PCP Offices
$25 per visit
PCP is chosen from PMP Directory Network
Referred Specialists
$50 per visit
Surgical Services
No charge
Treatment rooms and all appropriate equipment
No charge
Application, changes, removal of dressings, splints, plaster cast and removal of sutures
No charge
 Medical supplies for use at Provider's Office/Facility
No charge
 Laboratory Examinations and Services
No charge
 Periodic physical examinations
No charge
 Well child care and pediatric services
No charge
 Health Education
 No charge
 Immunizations
 $10 per Vaccine/Immunization Agent
Allergy Testing
$50 per visit
Allergy Visits & Immunotherapy
$10 per visit
Podiatry Services
$10 per visit
Chiropractic Services
$10 per visit
Routine Vision and Hearing Examinations
$10 per visit
Therapeutic and Diagnostic Services
$0 - $400
Inpatient Services
Major Procedures and Surgeries
$400 - 1500
Semi-private room, board, nursing care and meals
$500 X day for 5 days
$0
Intensive, critical, special and coronary care units
Co-payment*
Operating, treatment and recovery rooms
 No charge
Drugs, medicine, intravenous injections and solutions prescribed by attending Physician for use in the Hospital
 No charge
Medical supplies for use in the hospital
 No charge
Oxygen and its administration
 No charge
Laboratory examinations, electrocardiograms and inhlation therapy
 No charge
Emergency and Urgent Care (UC) Services
Urgent Care Services
$40 per visit after regular office hours at Contracted UC Centers
Emergency

$100 per Emergency plus 25% of charges above $100. Emergency Services and Hospital Stays initiated through the Emergency Room, including Ambulance Service

 $250 per visit
Maternity
Maternity Services

$1,500 Co-Payment. 15 months Waiting Period.

*** Deductible Does Not Apply ***
Prescriptions
Generic Prescriptions Only, except non-generic, non-prescriptions and contraceptives
$10/$15/$20/$30/50%
per prescription at Contracted Pharmacies
Optional Riders
Vision add $5.00 / month
Dental add $6.00 / month

Annual Deductible that applies to services listed above is $5,000 per Member per calendar year. Maximum annual out-of-pocket costs is $5,000 per Member per calendar year, not including any amount paid toward the fulfillment of the Deductible as well as copayments for Emergency Services and Care, and other services outlined in the applicable Attachment A, Schedule of Benefits and Covered Services. Total dollar annual benefit for essential benefits is $1,250,000 per Member per policy year.

This is not a contract. All services must be pre-authorized by the Health Plan, except for Emergency Care. For specific benefits, exclusions, copayments and limitations, see the applicable Individual Medical and Hospital Services Contract offered by Preferred Medical Plan, Inc. 4950 SW 8th Street, Coral Gables, FL 33134. Above benefits are based on FORM NO. PMP-HOSP-1-(10/10) and ATT-A-(10/10), et. al for Plans R5A, R5B & R5BB; and FORM NO. PMP-HOSP-1-(12/10) and ATT-A-(12/10) for Plan R5C. Prices subject to change. You may contact PMP at (305) 648-4015, if you have questions.

*Under the Affordable Care Act, certain preventive services will be covered without you having to pay a copayment or coinsurance. Please refer to FORM NO.PMP-HOSP-1-ATT-A-(10/10) for Plans R5A, R5B & R5BB; and FORM NO. HOS-1-ATT-A (12/10) FOR Plan R5C for details.