Description of Coverage - Premier Plans
Plan Name
A
B
C
Deductible
$0
$0
$0
Outpatient Services
Primary Care Physician (PCP)
$5 per visit
PCP Provided at Contracted Plan A PCP Offices
$10 per visit
PCP is chosen from PMP Directory Network
Specialists / Sub-Specialist
$10 per visit / $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 & Health Education
No charge*
Well child care and pediatric services
No charge*
Affordable Care Act Required Preventive Services
No charge*
Immunizations
No charge*
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
No charge*
Therapeutic and Diagnostic Services
$100-$400
Inpatient Services
Major Procedures and Surgeries
$400-$1500
Semi-private room, board, nursing care and meals
No charge
Intensive, critical, special and coronary care units
$500 x day for first 5 days
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
Maternity
Maternity Services
Not Covered
Emergency and Urgent Care (UC) Services
Urgent Care Services
$40 per visit after regular office hours at Contracted UC Centers
Emergency Services and Hospital Stays initiated through the Emergency Room, including Ambulance Service

$100 per Emergency plus 25% of charges above $100.
$250 per visit
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

*The sum of all co-payments will not exceed $5,000.00 per member per calendar year, except these limits are not applicable to co-payments for Emergency Services and Care and other services outlined in Attachment A. Total dollar annual limit will not exceed $1,250,,000 per member per policy year for essential benefits. This is not a contract. All services must be pre-authorized by the Health Plan, except for emergency care. For specific benefits, exclusions co-payments and limitations, see theapplicable Individual Medical and Hospitals Services Contract offered by Preferred Medical Plan, Inc., 4950 SW 8th St, Coral Gables, FL 33134.

Above benefits are based on FORM NO. PMP HOSP-1-(12/11) and ATT-A-(12/11) et.al. for Plans NA; NB; NBRX & NC, as applicable. 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 toFORM NO. PMP-HOSP-1-ATT-A-(12/11) for Plans NA; NB; NBRX & NC, as applicable, for details.