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PatriotCare Premium Plan

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PatriotCare Premium - Comprehensive Healthcare Benefit

The PatriotCare Premium Plan combines unlimited outpatient visits (primary care, specialists, urgent care), annual wellness exam and preventive care, prescription benefits, 24/7 virtual urgent care and virtual behavioral health beneifts with comprehensive healthcare benefits facilitated through a medical share plan which provides for emergency room visits, hospitalization, surgery, maternity and more.

Premium Plan Benefits Highlight

Comprehensive Care benefits are facilitated through a medical share plan. There are no network requirements for comprehensive care needs. The maximum out-of-pocket expense (IUA) for comprehensive care needs is either $1000 or $2500. This out-of-pocket cost is limited to a maximum charge of 3 times within a 12 month calendar period from the date of first comprehensive care event. If there a more than 3 comprehensive care needs within the same 12 month period, no additional out-of-pocket expense is assessed and the plan covers 100% for all eligble comprehensive care needs.

There are no annual or lifetime limits to the amount or frequency of comprehensive care benefits.
 
Network Requirement No network requirement for comprehensive care needs
Max. Out-of-Pocket (IUA) $1000 or $2500 IUA is applied per comprehensive care needs/per plan. Maximum 3 times within same 12 month period from the date of the first comprehensive care need.
Inpatient Benefits
Hospitalization includes admission and confinement Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Intensive Care Unit and sub-acute ICU Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Emergency Room admission Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Surgery includes anesthesia Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Diagnostic Labs and Imaging (PET, CT, MRI, X-ray, EEG, Lab Tests, Gastroenterology) Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Physician and Specialist doctor visits during hospital stay Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Outpatient Benefits
Surgery includes anesthesia, physican, and facility fees Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Physical rehabilitation therapy Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Diagnostic Labs and Imaging (PET, CT, MRI, X-ray, EEG, Lab Tests, Gastroenterology) Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Outpatient physican and specialist visits related to comprehensive care needs Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Maternity Benefits
Pre-natal Physician and OBGYN visits Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Birth / Delivery (hospital, birthing center, at home) Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Surgery (mother and child) Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Hospital admission and confinement (mother and child) Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
NICA and sub-acute NICU Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
Emergency Room with admission Covered 100% for all shareable medical needs after $1000 or $2500 IUA is met
End of Life Benefits
Shareable for all services required at time of detah for a particpating active member. End of life benefit is paid once per decedent.
Primary member or spouse $10,000
Child dependent $2,500
Outpatient services not related to a comprehensive care need are facilitated through the Multiplan PHCS network.
 
Primary Care Doctor Visits $15 co-payIn-network Benefit Only
Specialist Doctor Visits $15 co-payIn-network Benefit Only
Urgent Care Visit Visits $50 co-payIn-network Benefit Only
Annual Wellness Exam & Preventive Care Covered 100%In-network Benefit Only

COVERED WELLNESS & PREVENTIVE CARE SERVICES

ANNUAL WELLNESS EXAM
  • 1 wellness exam per year per insured. Covers medical history review, measurements (height, weight, body mass index), and exam.
  • Age and biological gender specific preventive care services, as detailed below
PREVENTIVE SERVICES ADULTS (AGES 18+)
  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
  • Blood Pressure screening
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults 45 to 75
  • Depression screening
  • Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
  • Diet counseling for adults at higher risk for chronic disease
  • Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over living in a community setting
  • Hepatitis B screening for people at high risk
  • Hepatitis C screening for adults age 18 to 79 years
  • HIV screening for everyone age 15 to 65, and other ages at increased risk
  • PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
  • Immunizations for adults — doses, recommended ages, and recommended populations vary: Chickenpox (Varicella), Diphtheria, Flu (influenza), Hepatitis A, Hepatitis B, Human Papillomavirus (HPV), Measles, Meningococcal, Mumps, Whooping Cough (Pertussis), Pneumococcal, Rubella, Shingles, and Tetanus
  • Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
  • Obesity screening and counseling
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Statin preventive medication for adults 40 to 75 years at high risk
  • Syphilis screening for all adults at higher risk
  • Tobacco use screening for all adults and cessation interventions for tobacco users
  • Tuberculosis screening for certain adults with symptoms at high risk
PREVENTIVE SERVICES WOMEN (AGES 18+)
  • Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
  • Breast cancer genetic test counseling (BRCA) for women at higher risk (counseling only; not testing)
  • Breast cancer mammography screenings: every 2 years for women over 50 and older or as recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
  • Breast Cancer chemoprevention counseling for women at higher risk
  • Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
  • Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
  • Cervical Cancer screening: Pap test (also called a Pap smear) for women 21 to 65
  • Chlamydia infection screening for younger women and other women at higher risk
  • Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
  • Domestic and interpersonal violence screening and counseling for all women
  • Folic acid supplements for women who may become pregnant
  • Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Maternal depression screening for mothers at well-baby visits
  • Preeclampsia prevention and screening for pregnant women with high blood pressure
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Sexually Transmitted Infections counseling for sexually active women
  • Expanded tobacco intervention and counseling for all pregnant tobacco users
  • Urinary incontinence screening for women yearly
  • Urinary tract or other infection screening
  • Well-woman visits to get recommended services for women
PREVENTIVE SERVICES CHILDREN (AGES 0-17)
  • Alcohol, tobacco, and drug use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Bilirubin concentration screening for newborns
  • Blood Pressure screening for children: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Blood screening for newborns
  • Depression screening for adolescents beginning at age 12
  • Developmental screening for children under age 3
  • Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years for children at higher risk of lipid disorders
  • Fluoride supplements for children without fluoride in their water source
  • Fluoride varnish for all infants and children as soon as teeth are present
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
  • Height, weight and body mass index (BMI) measurements taken regularly for all children
  • Hematocrit or hemoglobin screening for all children
  • Hemoglobinopathies or sickle cell screening for newborns
  • Hepatitis B screening for adolescents at higher risk
  • HIV screening for adolescents at higher risk
  • Hypothyroidism screening for newborns
  • PrEP (pre-exposure prophylaxis) HIV prevention medication for HIVnegative adolescents at high risk for getting HIV through sex or injection drug use
  • Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary: Chickenpox (Varicella); Diphtheria, Tetanus, and Pertussis (DTaP); Haemophilus influenza type B; Hepatitis A; Hepatitis B; Human Papillomavirus (HPV); Inactivated Poliovirus; Influenza (flu shot); Measles; Meningococcal; Mumps; Pneumococcal, Rubella; and Rotavirus  Lead screening for children at risk of exposure
  • Obesity screening and counseling
  • Oral health risk assessment for young children from 6 months to 6 years
  • Phenylketonuria (PKU) screening for newborns
  • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Vision screening for all children
  • Well-baby and well-child visits
Prescription drug benefits are subject to the formulary drug list.
Co-pay amounts listed are based on a unit quantity of 30 for a 30-day supply. Pricing may vary based on quantity and supply.
Tier I medications $15 co-pay
Tier II medications $30 co-pay
Tier III medications $50 co-pay
Tier IV medications $75 co-pay
Virtual Care program includes unlimited 24/7 access to virtual urgent care with board-certified doctors via phone, video or messaging and connects members with a Psychiatrist or Licensed Counselor through secure and private online video or phone sessions at $50 each (first 3 visits - $85 after).
24/7 Virtual Urgent Care 100% covered
Virtual Behavioral Health $50 fee (first 3 visits then $85 fee after)

Have Questions?

Get the answer today...Call us (682)437-1724 or schedule a call back.