Medvantage Plan with Optional Point of Service Benefit
(No Part D Prescription Benefit) 2012

Questions:

If you have questions or require assistance, please call:
FHCP's Marketing Department at 1-800-232-0578, TTY users please call TTY: TRS Relay 711.

Hours of operation: 7 days a week / 8:00 a.m. - 8:00 p.m.

Click here to review the Basic Benefit Information Disclaimer
Click here to review the Online Enrollment Center Disclaimer

2012 Benefits at a glance

PREMIUM AND OTHER IMPORTANT INFORMATION:

Monthly Premium:

$20.00*

Maximum Medical Out-of-Pocket: 

In-Network $6,700

Out-of-Network $8,000

*You must continue to pay your Medicare Part B premium.

PHYSICIAN SERVICES:

 
In-Network:  
Out-of-Network:
Primary Care Physician
Specialist
$10 copay/visit $30 copay/visit
$40 copay/visit $40 copay/visit

Doctor Choice: You may go to any provider that accepts Medicare assignment or utilize our HMO Provider Network, without a referral.
Specialist Referral Required: No referral required

INPATIENT CARE:

Inpatient Hospital Care:
  
In-Network:
$200 per day (days 1-8)
Out-of-Network:
$200 per day (days 1-10)
 
Skilled Nursing Facility:
  
In-Network:
 $0 per day (days 1-7)
  $50 per day (days 8-100)
Out-of-Network:
 $175 per day (days 1-58)

 


OUTPATIENT CARE:

Outpatient Mental Health Care:
  
In-Network:
 $30 copay for each Medicare-covered individual or group therapy visit
Out-of-Network:
 $40 copay for each Medicare-covered individual or group therapy visit
 
Outpatient Substance Abuse Care:
  
In-Network: $30 copay for each Medicare-covered individual or group therapy visit
Out-of-Network: $40 copay for each Medicare-covered individual or group therapy visit
 
Outpatient Services/Surgery:
  
In-Network:
 $100 copay for each Medicare-covered ambulatory surgical center visit.
  $0 to $200 copay for each Medicare-covered outpatient hospital facility visit
Out-of-Network:
 20% coinsurance each Medicare-covered ambulatory surgical center visit or outpatient hospital facility visit
   
Emergency Care:
  
In & Out-of-Network: $65 copay for Medicare-covered emergency room visits Worldwide coverage
   
Urgently Needed Care:
  
In & Out-of-Network: $30 copay for Medicare-covered urgently needed care visits
   
Ambulance Services:
  
In & Out-of-Network: $175 copay for Medicare-covered ambulance benefits
   
Outpatient Rehabilitation Services:
  
In-Network: $30 copay for Medicare-covered Occupational Therapy visits, Physical and/or Speech and Language Therapy visits.
Out-of-Network: $40 copay for Medicare-covered Occupational Therapy visits, Physical and/or Speech and Language Therapy visits.

OUTPATIENT MEDICAL SERVICES AND SUPPLIES

Durable Medical Equipment:
  
In & Out-of-Network:
 20% of the cost for Medicare-covered items
 
Prosthetic Devices:
  
In & Out-of-Network:
 20% of the cost for Medicare-covered items
 
Diagnostic Tests, X-rays, Lab Services, and Radiology Services:
 
In-Network
 $0 copay for Medicare-covered lab services
$0 to $175 copay for Medicare-covered diagnostic procedures and tests
$10 to $25 copay for Medicare-covered X-rays
$10 to $200 copay for Medicare-covered diagnostic radiology services
$10 to $25 copay for Medicare-covered therapeutic radiology services
Out-of-Network
 20% coinsurance
 
Cardiac and Pulmonary Rehabilitation Services:
 
In-Network:
 $30 copay for Medicare-covered Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, and Pulmonary Rehabilitation Services
Out-of-Network:
 $40 copay for Medicare-covered Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation In-Services, and Pulmonary Rehabilitation Services    
 
Hearing Services:
 $0 copay for Medicare-covered diagnostic hearing exams
(In-Network only)
 $0 copay for:
  • Up to 1 supplemental routine hearing test(s) every year
  • Up to 1 fitting evaluation(s) for a hearing aid every year
 
Vision Services:
 $15 copay for a Medicare-covered eye exam by an Optometrist
(In-Network only)
 $30 copay for a Medicare-covered eye exam by an Ophthalmologist, referral required
Covered up to a $90 credit toward the purchase of eyeglasses from a participating Optometrist every two years

ADDITIONAL BENEFITS:

  • Preferred Fitness program - access to over 30 contracted gyms in Volusia & Flagler Counties
  • 24-Hour Member Only Nurse line - English and Spanish
  • Member Portal and Welcome to Wellness online Health Risk Assessment - providing education and programs to help FHCP Medvantage Members take a more active role in their healthcare.
  • Matter of Balance


To View Full Medvantage with Optional Point of Service Plan Details:

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