Benefit Levels

2017 Voucher Benefit Levels Effective 2/1/17

COMMUNITY HEALTH SERVICE PAYS FOR THE FOLLOWING: (Please note this program may not cover all costs/charges to outside facility/provider.)

MAXIMUM PAID

OFFICE VISIT – Usual and customary charge up to: With a Signed Physician Agreement – accepted as payment in full for the Office Visit Only (CPT Codes 99201-99215)   $150.00 Without a Signed Physician Agreement – Office Visit Only

(Patient may be responsible for balance owed on office visit) $100.00 Specialist (one per year, plus one follow-up visit – patient may be responsible for balance owed to the provider)      $150.00 per visit

VISION

Refraction (92015)                                                                       $40.00 annually

Exam (92002 or 92012)                                                             $140.00 annually

 

MEDICAL LAB/X-RAY/EKG                                                  $200.00 per day

READING OF LAB/X-RAY                                                      $60.00

PRENATAL CARE PAYMENT LEVELS

Office Visit                                                                               $100.00

Ultrasound (Medically necessary)                                     $125.00

Ultrasound Reading                                                              $75.00

DELIVERY/MISCARRIAGE

Mother: If D&C isn’t needed would be OV only $750.00.  Baby:   $500.00

DENTIST                                                                           $200.00 per patient/per year

PHARMACY

Prescriptions (30 day supply)                                        $100.00 every 30 days

Prescriptions (90 day supply)                                        $150.00 every 90 days

If the voucher includes an Rx for insulin up to $200.00 every 30 days up to $600.00 every 90 days (Please refer to the attached list of medications that are not covered.)

2016 Benefit Levels Effective 2/1/16

COMMUNITY HEALTH SERVICE PAYS FOR THE FOLLOWING:

(Please note this program does NOT cover ALL your medical costs.)

                                                                                                                                     MAXIMUM PAID

OFFICE VISIT – Usual and customary charge up to:

With a Signed Physician Agreement – accepted as payment

in full for the Office Visit Only (CPT Codes 99201-99215)                                          $150.00

Without a Signed Physician Agreement – Office Visit Only

(Patient may be responsible for balance owed on office visit)                                    $100.00

Specialist (one per year, plus one follow-up visit – patient may be

responsible for balance owed to the provider)                                                            $150.00 per visit

 

VISION

Refraction                                                                                                                    $40 annually

Retinopathy                                                                                                                 $140 annually

 

MEDICAL LAB/X-RAY/EKG                                                                                       $200 per day

(Combination of all procedures or 1 procedure only done at time of visit)

 

LAB/X-RAY READINGS                                                                                               $60.00

 

PRENATAL CARE PAYMENT LEVELS

Office Visit                                                                                                                    $100.00

Lab/Ultrasound (at 18+ weeks, if necessary)                                                               $125.00

Ultrasound Reading                                                                                                       $75.00

 

DELIVERY/MISCARRIAGE

Mother: If D&C isn’t needed would be OV only                                                           $750.00

Baby:                                                                                                                            $500.00

 

DENTIST (Diagnosis V72.2)                                                                        $200 per patient/per year

 

PHARMACY

Prescriptions ONLY                                                                                              $100 every 30 days

If the voucher includes a Rx for insulin                                                            up to $200 every 30 days