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BENEFIT CATEGORY |
MEMBER RESPONSIBILITY |
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PCP AND
SPECIALIST PHYSICIAN SERVICES |
$15 Copayment
$30 Copayment |
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WELL
WOMAN EXAM
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$15 PCP or $30 OB/GYN
Copayment
Must be rendered by your PCP or contracting OB/GYN
(a referral is not required) |
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OUT-OF-POCKET COPAYMENT MAXIMUM |
Individual $1,500
Family $3,000 |
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LIFETIME
MAXIMUM |
$2,000,000
The lifetime maximum will include benefits you have accumulated
under another PPK health plan offered by the same employer prior
to this coverage. |
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OUTPATIENT LAB AND
X-RAY |
No Copayment |
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INPATIENT BENEFITS*
(Semi-Private Room, ICU, SNU, Hospice) |
$200 Copayment per day; $1,000 per
Member per Benefit Period;
$2,000 per family maximum, per Benefit Period |
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MATERNITY CARE
Prenatal and Postpartum Services |
Services must be
rendered by your PCP or contracting OB/GYN
$250 Physician Copayment in lieu of PCP or OB/GYN office
visit Copayment |
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Inpatient
Services* |
Subject to inpatient benefits |
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OUTPATIENT SURGERY* |
$250 Copayment |
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ALLERGY
TREATMENTS |
No Copayment |
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IMMUNIZATIONS |
No Copayment |
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DEPENDENT CHILDREN |
Physician Office Visit $30 Copayment;
Physical Therapy $30 Copayment |
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OUT OF AREA CARE*
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Coverage outside
the Service Area for Dependent children is limited to Physician
office visits, allergy shots, allergy treatment, and physical
therapy. Services must be received from Contracting Providers,
referred by the Dependent's PCP, and prior authorized by PPK.
This benefit does not include routine or preventive services
such as immunizations, physicals, or maternity care. |
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INPATIENT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE*
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Subject to inpatient benefits
Services must be prior authorized by PPK by calling
316-609-2541 or 1-866-338-4281 (outside Wichita).
Maximum benefit limited to thirty (30) days per Member, per
Benefit Period. Each partial day session will count as one half
inpatient day toward the thirty (30) day benefit. |
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INPATIENT BIOLOGICALLY BASED MENTAL ILLNESS*
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Subject to inpatient benefits
Services must be prior authorized by PPK by calling 316-609-2541
or 1-866-338-4281 (outside Wichita).
Maximum benefit limited to forty-five (45) days per Member, per
Benefit Period. Each partial day session will count as one half
inpatient day toward the forty-five (45) day benefit.
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OUTPATIENT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE* |
100% of Allowed Amounts of the
first three (3) visits;
then 70% of Allowed Amounts.
Services must be prior authorized by PPK by calling 316-609-2541
or 1-866-338-4281 (outside Wichita). |
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OUTPATIENT BIOLOGICALLY BASED MENTAL ILLNESS*
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Subject to Applicable PCP or
specialist Physician Copayments
Services must be prior authorized by PPK by calling 316-609-2541
or 1-866-338-4281 (outside Wichita).
Maximum benefit limited to forty-five (45) visits per Member,
per Benefit Period. |
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EMERGENCY SERVICES IN THE SERVICE AREA
There
is no coverage for non Emergency Medical Conditions treated in a
Hospital emergency room
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$100 Hospital emergency room
Copayment
at a contracting Hospital
$200 Hospital emergency room Copayment
at a non contracting Hospital
$30 urgent care facility Copayment
If admitted, Copayment will be waived and inpatient
benefits will apply. |
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If you receive Emergency
Services from a non-contracting Hospital within the Service Area
under circumstances where you have the ability to determine when
or where to seek such services, you will be responsible for the
difference between the Provider's billed charges and Allowed
Amounts. If admitted, you will also be responsible for a $1,000
penalty, per admission. In situations where you require
Emergency Services and have no control when or where such
services are rendered, you will not be responsible for the
difference between the Provider's billed charges and Allowed
Amounts, or the $1,000 penalty. |
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EMERGENCY SERVICES OUT OF THE SERVICE AREA
(If Emergency Medical Condition) |
$100 Hospital emergency room
Copayment
$30 urgent care facility Copayment
If admitted, Copayment will be waived and inpatient
benefits will apply. |
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AMBULANCE |
No Copayment |
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DURABLE
MEDICAL EQUIPMENT* |
No Copayment
Maximum benefit limited to $1,000 of Allowed Amounts
per Member, per Benefit Period. |
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DISPOSABLE MEDICAL SUPPLIES
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No Copayment |
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Coverage is limited to $500 per
Member, per Benefit Period for the following:
- Ostomy (appliance pouches, skin care agents, support belts)
- Open wound (gauze pads, wound packing strips, ABD pads)
- Venous access catheter (alcohol pads, benzoin, dressings)
- Urinary supplies (catheter and bag supplies)
- Tracheostomy supplies
- Supplies used in conjunction with Durable Medical Equipment
- Inhaler supplies (aero chamber mask, spacers, peak flow
meters) |
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DIABETIC
EQUIPMENT AND SUPPLIES |
No Copayment
Must be purchased from Contracting Providers and referred
by
your PCP. |
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RECONSTRUCTIVE SURGERY FOLLOWING A MASTECTOMY
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Subject to Applicable Copayments |
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Coverage will be provided in a
manner determined in consultation with the treating Physician
and the Member for reconstruction of the breast on which the
mastectomy has been performed; surgery and reconstruction of the
other breast to produce symmetrical appearance; prostheses and
physical complications during all stages of the mastectomy,
including lymphedema. |
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HOME
HEALTH CARE
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No Copayment
Maximum benefit limited to $2,500 of Allowed Amounts per Member,
per Benefit Period. |
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INTRAVENOUS (IV) AND INJECTABLE MEDICATIONS* |
No Copayment
Prior Authorization is required for outpatient Facility and
if
given in the home |
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OUTPATIENT HOSPICE SERVICES |
No Copayment |
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OUTPATIENT SPEECH THERAPY |
$30 Copayment
Maximum benefit limited to $1,500 of Allowed Amounts per Member,
per Benefit Period. |
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INPATIENT REHABILITATION*
(Speech, Physical, Occupational, Cardiac) |
Subject to inpatient benefits
Maximum benefit limited to sixty (60) days per Member, per
medical condition, per Benefit Period. |
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OUTPATIENT REHABILITATION
(Physical, Occupational, Cardiac and Spinal Manipulations) |
$15 PCP Copayment
$30 specialist Copayment
Maximum benefit limited to $5,000 of Allowed Amounts per
Member,
per Benefit Period. |
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ORTHOTICS AND PROSTHETICS* |
No Copayment
Coverage is limited to the original device unless repair and/or
replacement is Medically Necessary. |
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ORAL
SURGERY AND RELATED SERVICES |
Subject to Applicable Copayments
Services for accidental injury to sound, natural teeth will be
covered up to a maximum of $1,000 of Allowed Amounts, if
provided within twelve (12) months from the date of injury. |
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TRANSPLANT SERVICES*
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Subject to Applicable Copayments |
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Members are entitled to receive
benefits for human organ and tissue transplant services through
Contracting Providers. Transplants covered include: Bone
marrow (allogenic or autologous); Cornea; Heart; Heart-Lung;
Lung (single or double); Intestine; Liver; Kidney; and
Pancreas. |
PRESCRIPTION DRUGS
NETWORK
34 DAY SUPPLY
BENEFIT
90 DAY SUPPLY
BENEFIT
FORMULARY
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Certain medications require Prior Authorization
Preferred Options Network
Retail Pharmacy: A 34-day supply, as specified by the quantity
sufficient for a standard course of therapeutic treatment as
defined by FDA guidelines, or 100 unit dose of tablets or
capsules, whichever is less.
Covered generic prescriptions are subject to a $3 Copayment.
Covered brand name prescriptions are subject to a 50%
Coinsurance payment, per prescription. However, no Member will
be require to pay more than $100 in Coinsurance per Covered
Prescription. The difference between the actual billed charges
of a Non-Contracting Pharmacy and the PPK Allowed Amounts does
not apply to the out-of-pocket maximum.
Oral Contraceptives may be dispensed in a three month supply at
a retail pharmacy; however, the Copayment/Coinsurance is
required for each month's supply
Mail Order Pharmacy: A 90-day supply, as specified by the
quantity sufficient for a standard course of therapeutic
treatment as defined by FDA guidelines.
Generic prescriptions are subject to $10 Copayment, per Covered
Prescription. Brand name prescriptions are subject to a 50%
Coinsurance payment, per Covered Prescription. However, the
Member will not be required to pay more than $250 in
Coinsurance, per Covered Prescription
Preferred Choice Formulary
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*These services require Prior Authorization
by PPK.
Prior Authorization Process
Prior Authorization is the process of PPK determining
whether the Health Care Service is a Covered Service, Medically
Necessary, and being rendered by Contracting Providers. Coverage
is subject to eligibility and benefits remaining at the time
services are rendered.
Referral Process
PPK Members are responsible for obtaining a referral
authorization from their PCP for all Health Care Services
(except Emergency Services, annual well-woman exam, annual
diabetic retinal eye exam, and prospective parent PCP visit)
rendered outside his/her office. Behavioral health, substance
abuse, and Biologically Based Mental Illness services do not
require a PCP referral authorization; however, they must be
Prior Authorized by PPK.
Limitations and Exclusions
*Services not provided, ordered or referred by your PCP,
(except for emergency services, annual well-woman exam, annual
diabetic retinal eye exam, and prospective parent visit).
*Services not medically necessary
*Cosmetic treatment/surgery primarily to restore or alter
appearance, surgical treatment of obesity (including morbid
obesity), medical services in conjunction with prescription
weight loss therapy, and weight loss programs unless approved by
PPK.
*Experimental and investigational treatment unless otherwise
specified in Certificate.
*Services for injuries or diseases related to employment and
covered under a Workers Compensation program and services
resulting from injuries related to a motor vehicle accident and
should be or are covered under automobile insurance.
*Duplication of benefits provided by Federal, State or local
law, such as Medicare, CHAMPUS, and services in any veteran’s
facility.
*Services from non-contracting providers unless referred by your
PCP and prior authorized by PPK.
*Items not strictly to treat a medical condition, including but
not limited to, shower chairs, breast pumps, prenatal cradle.
The Certificate you will receive when you enroll will contain
complete benefit descriptions, exclusions and limitations.
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