HomeMy WebLinkAboutCity of Tamarac Resolution R-2000-2861
Temp. Reso. #9191 - October 23, 2000
Revision #1-October 31, 2000
Page 1
CITY OF TAMARAC, FLORIDA
RESOLUTION NO. R-2000- c2M
A RESOLUTION OF THE CITY COMMISSION OF
THE CITY OF TAMARAC, FLORIDA,
AUTHORIZING THE APPROPRIATE CITY
OFFICIALS TO EXECUTE THE RENEWAL OF
HEALTH INSURANCE COVERAGE WITH HIP
EFFECTIVE JANUARY 1, 2001 WITH A RATE
INCREASE OF 8% HMO AND 15% POS/PPO;
PROVIDING FOR THE CONTINUATION OF THE
EXISTING COST ALLOCATION OF THE HEALTH
INSURANCE PREMIUM BETWEEN THE CITY
AND EMPLOYEES; APPROVING THE
APPROPRIATE BUDGETARY TRANSFERS OF
FUNDS; PROVIDING FOR CONFLICTS;
PROVIDING FOR SEVERABILITY; AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City's health insurance was awarded to HIP effective
January 1, 1999 with a three year contract, containing annual renewal cap rates
of 8% HMO and 15% PPO/POS, renewing on January 1, 2001; and
WHEREAS, the rates for health insurance coverage have increased this
renewal period; and
WHEREAS, the health insurance rate will increase 8% HMO and 15%
PPO/POS effective January 1, 2001; and
WHEREAS, the Personnel Director recommends the renewal of the health
insurance coverage with HIP effective January 1, 2001; and
Temp. Reso. #9191 - October 23, 2000
Revision #1-October 31, 2000
Page 2
WHEREAS, available funds exist in the appropriate funds which are in
the approved FY2001 Budget; and
WHEREAS, the City Commission has deemed it to be in the best interest
of the citizens and residents of the City of Tamarac to renew the health
insurance benefits for the City employees, as provided by HIP.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF TAMARAC, FLORIDA:
SECTION 1: That the foregoing "WHEREAS" clauses are hereby
ratified and confirmed as being true and correct and are hereby made a specific
part of this Resolution.
SECTION 2: That the appropriate City officials are hereby
authorized to execute the renewal of HIP as the City's carrier for health
insurance coverage for City of Tamarac employees effective January 1, 2001
with a rate increase of 8% HMO and 15% POS/PPO, said renewal attached
hereto as Exhibit #1. The monthly rates shall be increased as follows: HMO
$147.19 to $158.97 for single coverage; $410.20 to $443.02 for family
coverage; POS $219.58 to $252.52 for single coverage; $ 603.71 to $ 694.27
for family coverage; PPO $252.15 to $289.97 for single coverage; $688.25 to
$791.49 for family coverage.
P
Temp. Reso. #9191 - October 23, 2000
Revision #1-October 31, 2000
Page 3
SECTION 3: That the appropriate City officials are hereby
authorized to continue the existing cost allocation of the health insurance
premium between the City and the employees.
SECTION 4: That the appropriate City officials are authorized to
enact any appropriate budget transfers as needed for this purpose.
SECTION 5: That all resolutions or parts of resolutions in conflict
herewith are hereby repealed to the extent of such conflict.
SECTION 6: That if any clause, section, or other part or
application of this Resolution is held by any court of competent jurisdiction to be
unconstitutional or invalid, in part or application, it shall not affect the validity of
the remaining portions or applications of this Resolution.
1
Temp. Reso. #9191 - October 23, 2000
Revision #1 -October 31, 2000
Page 4
SECTION 7: This Resolution shall become effective immediately
upon adoption.
PASSED, ADOPTED AND APPROVED this day of 12000.
ATTEST:
MAR.TOK SWENSON, CMC
CITY1CLtkk`
I HEREB'Y,CERTIFY that
Have approved this /
`4SOtUT, ONoss to foray
I ITCHELL S. I
CITY ATTORN
JOE SCHREIBER
MAYOR
RECORD OF COMMISSION V TE
MAYOR SCHREIBER
V ❑IST t : COMM. PORTNER
DIST 2: COMM. MISHKIN
COT a: COW SULTANOF
DW 4: Vim mmon
i . ,f
Lxhibit 91
Temp. Reso. #9191
am
HEALTH PLAN OF FLORIDA
October 25, 2000
Maria Swanson
City of Tamarac
7525 NW 88 h Avenue
Tamarac, Fl 33321
Dear Maria,
Thank you for allowing HIP Health Plan of Florida the opportunity to continue to serve the employees of
the City of Tamarac this past year. This letter will confirm. the HIP Health Plan of Florida rates and
benefits for the City of Tamarac for contract year beginning January 1, 2001 through December 31, 2001.
Single
Family
HIP HMO Plan 100 $158.97
$443.02
HIP POS Plan 218 $252.52
$694.27
HIP PPO Plan 971 $289.97
$791.49
Please note the following conditions apply to the rates quoted above:
• Rates are valid for effective date quoted.
• Rates are guaranteed for one (1) year from the effective date.
• All rates are subject to Underwriting approval
• HIP requires 75% participation for all eligible employees (HIP sole carrier only)
• Rates are based on current census (or census provided). HIP reserves the right to change the rate if the
census, at enrollment or at any time throughout the contract year changes by 10% or more.
• There are no benefit changes; all plans remain the same, including the ability for the physicians to
obtain override authorizations for Prescription Drugs.
We look forward to a long relationship between HIP Health Plan of Florida and the City of Tamarac.
Sincerely,
Carmen Miller
Senior Group Benefit Rep.
Accepted
Title:
Date:
//la(/14Wi
HIP HEALTH PLAN OF FLORIDA 300 SOUTH PARK ROAD • HOLLYWOOD. FL 33021 • 954,962.3008
HP481 2/00
r
HMO PLAN 100 SCHEDULE OF CO -PAYMENTS
ueri wru m &m me to neinw
HIP FORM 60013 1`21-1100-032 (CITY OF TAMARAC)
01/99
Igo I
HEALTH PLAN OF FLORIDA
HMO PLAN 100
SCHEDULE OF CO -PAYMENTS
A.
Physical and Speech Therapy (20 visits per acute condition).
$0
B.
Home Health Care (20 visits per acute episode).
$0
C.
Hospice Care (210 days lifetime maximum).
$0
D.
Skilled Nursing Facility (30 days per calendar year, 100 days per lifetime).
$0
E.
Second Medical Opinion
Services rendered by a Participating Provider.
Services rendered by a Non -Participating Provider within the service area.
$0
40% of customary
charges
F.
Outpatient Durable Medical Equipment ($5,000 annual maximum)
$25
G.
Ambulance Services.
$0
Inpatient - 30 days per calendar year
Partial hospitalization (1 inpatient day = 2 partial days)
Outpatient - 20 visits per calendar year
Inpatient - 30 days per calendar year
Outpatient - 44 visits per calendar year
There is a maximum lifetime benefit of $4,500 for Inpatient and Outpatient services
combined
same as Hospital
Copay
$0
same as
Hospital Copay
HIP pays $35
per visit
HIP FORM 60013 P21-1100-032 (CITY OF TAMARAC) 01/99
HMO PLAN 100
SCHEDULE OF CO -PAYMENTS
HEALTH PLAN OF FLORIOA
HIP FORM 60013 P21-1100-032 (CITY OF TAMARAC) 01/99
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
HEALTH PLAN OF FLORIDA
Formulary
Generic Drugs
Brand Name Drugs (If no generic equivalent is available or permitted by law.)
Contraceptives
Non -Formulary
Generic Drugs
Brand Name Drugs (If no generic equivalent is available or permitted by law.)
Contraceptives
Infertility Drugs
Limited to a 30-day supply (or 120 units) each time a prescription order is filled. When a
Member is expected to be absent from the Service Area and when pre -approved by HIP,
up to a 90-day supply may be obtained at one time.
Infertility Drugs
A 90-day supply is covered each time a prescription order is filled. (The HIP physician must
prescribe a 90-day supply. Refills cannot be combined to obtain a 90-day supply.)
$25
$25'
$25
Not Covered
$5
$10
$5
$25
$25
$25
Not Covered
HIP# 50338 03/97 7/1/99
(R2HRCX)
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
HRA1.9'H PLAN OF FLORIDA
A. Definitions. All terms used in this Rider shall have the respective meanings specified in the Group Master
Contract and Certificate of Coverage, unless the context otherwise requires. Further, as used in this Rider:
"Covered Drugs" shall mean any Legend Drug that is included in the HIP Drug Formulary and is dispensed by
a Participating Pharmacy according to a Prescription Order. This includes Non -Formulary Drugs obtained at the
higher copay. Covered Drugs includes contraceptive, infertility and impotency medications only if so indicated
in Section I and II above. Covered Drugs excludes those drugs indicated as Exclusions in Section III above.
Covered Drugs includes any medication compounded by a Participating Pharmacy according to a Prescription
Order whose components includes drugs included in the HIP Drug Formulary or the requested Non -Formulary
agent.
"HIP Drug Formulary" shall mean the listing of all prescription drugs approved for use by HIP.
"Non -Formulary Drug" shall mean prescription drugs not on HIP's Formulary, excluding items listed in Section
III.
"Legend Drug" shall mean any medicinal substance which the Federal Food, Drug and Cosmetic Act requires
to be labeled "Caution Federal Law prohibits dispensing without a prescription."
"Participating Pharmacy" shall mean a pharmacy contracted with HIP as a Participating Provider.
"Prescription Order" shall mean a written or oral request for Covered Drugs to a Participating Pharmacy (except
in the event of an Emergency while the Member is out of the Service Area, in which event the Prescription
Order need not be given to a Participating Pharmacy) by an HIP physician.
HIP# 50338 03/97 7/1 /99
(R2HRCX)
ISOM
HEALTH PLAN OF FLORIDA
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
B. Conditions.
1. The benefits and services covered by this Rider are limited to the benefits and services set forth
herein which are provided, prescribed, directed, authorized, or approved by HIP and its Participating
Providers.
2. The Premium for this Rider is set forth in the Binder and Agreement comprising part of the
Agreement. The terms and conditions regarding payment of the Premium for this Rider are as set
forth in the Agreement.
3. Nothing contained in this Rider shall be held to vary, alter, waive, supplement, or extend any of the
terms, conditions, provisions, agreements or limitations of the Agreement, other than as specifically
set forth below, and the provision of the Covered Services contemplated in this Rider shall be
governed by the terms and conditions of the Agreement with the Group.
4. Coverage under this Rider shall commence and terminate in accordance with the terms of the
Agreement.
C. Coverage. Coverage for Covered Drugs shall be provided subject to the following:
Coverage for Covered Drugs shall be provided only when obtained from a HIP Participating Pharmacy
pursuant to a Prescription Order made by an HIP physician, except in the event of an Emergency
condition arising while the Member is out of the Service Area;
2. Member shall be responsible for one Co -payment for each prescription or refill;
Participating Pharmacies will dispense only generic equivalent Covered Drugs when such generic
equivalents are available and allowed by law unless the prescribing physician deems the use of the
brand name Covered Drug to be Medically Necessary and indicates the same on the prescription
form. In such a case, the physician must obtain prior authorization from HIP. When the physician
obtains prior authorization from HIP, the Member is not required to pay the cost difference between
the generic and brand product;
Except as provided above, if the Member or the Member's physician requests a brand name drug
when a therapeutic equivalent generic drug is available and permitted by law, the Member shall be
responsible for paying the brand Co -payment plus the cost difference between the brand and
generic product.
3. Member shall be responsible to pay the full cost incurred for any drug not approved by HIP when
prior approval is required but not obtained;
4. When Member obtains a Covered Drug from a Participating Pharmacy at a time when Member does
not have the identification card available, Member shall pay for the full cost of the Covered Drug
and will be required to submit the receipt for same together with an appropriate claim form to HIP
for reimbursement, less applicable Co -payments. Member will not be reimbursed more than HIP's
contracted amount for drugs dispensed with Participating Pharmacies;
HIPS/ 50338 03/97 7/1 /99
(R2HRCX)
F 9 PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
HEALTH PLAN OF FLORIDA
5. If you are going on vacation or planning on being out of the Service area, then you need to obtain
the appropriate medication supply to take with you. You may request up to a 90-day vacation
supply. This is important because maintenance medications will ONLY be covered when you are
utilizing the Interplan Services. In addition, when utilizing the Interplan services, you are still
encouraged to obtain your medications at your local participating pharmacy before leaving the
Service area. This will allow you to avoid having to pay the full cost of the medication and then
submitting for reimbursement. You should contact the Customer Service Department to obtain
information regarding what participating pharmacies are available in the Interplan Program.
If you are out of the service area and are not in one of our Interplan areas, then ONLY medications
required for emergency care would be covered.
6. Medications obtained in association with required emergency care is covered so long as they are
covered under your benefit plan. You should contact the Customer Service Department for
information regarding available pharmacy locations outside of the service area. The utilization of
these pharmacies will enable you to pay for the prescription according to your benefit plan. If the
area you are visiting does not have a participating pharmacy available, for reimbursement submit
the itemized receipt along with a reimbursement form to the Claims Department.
HIP HEALTH PLAN OF FLORIDA, INC.
Daniel T. McGowan
President
HIP# 50338 03/97 7/1 /99
(R2HRCX)
A.
B
mid
HEALTH PLAN OF FLORIDA
HMO PLAN RIDER
Inpatient services (limited to 30 days per calendar year).
Outpatient services (limited to 20 visits per calendar year).
See In -Patient
Hospital Copay
$0
In consideration of the payment of all applicable Premiums, the HIP HEALTH PLAN GROUP Master Contract
is hereby amended and supplemented by the terms and conditions of this Rider.
A. Definitions. All terms used in this Rider shall have the respective meanings specified in the Group
Master Contract, unless the context otherwise requires.
Further, as used in this Rider:
1. "Mental Health Conditions" shall mean mental and nervous disorders as defined in the standard
nomenclature of the American Psychiatric Association.
2. "Partial Hospitalization" shall mean those services offered by a program accredited by the Joint
Commission on Accreditation of Health Organizations (JCAHO) or in compliance with equivalent
standards.
B. Conditions.
1. The benefits and services covered by this Rider are limited to the benefits and services set forth
herein which are Medically Necessary and are provided, prescribed, directed, approved, or approved
by HIP HEALTH PLAN and its Participating Providers, in accordance with the terms and conditions
of the Agreement.
2. The Premium for this Rider is set forth in the Binder and Agreement comprising part of the
Agreement. The terms and conditions regarding payment of the Premium for this Rider are as set
forth in the Agreement.
3. Nothing contained in this Rider shall be held to vary, alter, waive, supplement, or extend any of the
terms, conditions, provisions, agreements or limitations of the Agreement, other than as specifically
set forth below, and the provision of the Covered Services contemplated in this Rider shall be
governed by the terms and conditions of the Agreement.
4. Coverage under this Rider shall commence and terminate in accordance with the terms of the
Agreement.
5. If a Member incurs charges for any Covered Service provided under this Rider, other than a
required Co -payment, in order to receive reimbursement from HIP for the amount of the charge, a
claim must be submitted to HIP HEALTH PLAN as soon as reasonably practicable following the
date on which the Covered Service occurred, but in no event later than sixty (60) days after such
occurrence.
unails] 11105 YIxi151
1
HUM PLAN OF FLORIDA HMO PLAN RIDER
C. Benefits and Limitations.
1. Inpatient Benefits. Inpatient benefits for Mental Health Conditions are limited to those Mental Health
Conditions which are determined by the Primary Care Physician, Referral Specialist or Mental Health
provider to be responsive to short-term treatment and not to be chronic or organic in nature.
2. _Outpatient Benefits. The benefit shall consist of outpatient services for consultations, treatment,
evaluation and/or crisis intervention for Mental Health Conditions. To be Covered Services, such
services must be Medically Necessary and be provided by a physician, a psychologist licensed
pursuant to Chapter 490, Florida Statutes, a mental health counselor, marriage and family therapist,
or clinical social worker, in each case licensed pursuant to Chapter 491, Florida Statutes.
Partial Hospitalization Benefits. Partial Hospitalization benefits are limited to the treatment of mental
health conditions which are deemed by the Primary Care Physician and Referral Specialist to be
responsive to short term treatment and not to be chronic or organic in nature. In any benefit year,
if Partial Hospitalization services or a combination of inpatient and partial hospitalization are utilized,
the total benefits paid shall not exceed the cost of the number of days of inpatient benefits for
psychiatric services, including physician fees (based on physician fees which are usual and
customary in the community).
The benefits available to members hereunder shall not include coverage for treatment pursuant to
voluntary or involuntary confinement under Florida's Baker Act, Florida Statutes 394,451-394.4789,
whether such confinement is considered to be routine or an Emergency, except within the limits of
Paragraphs C (1) and C(2) above.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP 50346 I 1 /96
(R2HMEN)
111110 .]
A.
1
loll
HEALTH PLAN OF FLORIDA
HMO PLAN RIDER
Inpatient services (limited to 30 days per calendar year).
Outpatient services (limited to 20 visits per calendar year).
See In -Patient
Hospital Copay
$0
In consideration of the payment of all applicable Premiums, the HIP HEALTH PLAN GROUP Master Contract
is hereby amended and supplemented by the terms and conditions of this Rider.
A. Definitions. All terms used in this Rider shall have the respective meanings specified in the Group
Master Contract, unless the context otherwise requires.
Further, as used in this Rider:
1. "Mental Health Conditions" shall mean mental and nervous disorders as defined in the standard
nomenclature of the American Psychiatric Association.
2. "Partial Hospitalization" shall mean those services offered by a program accredited by the Joint
Commission on Accreditation of Health Organizations (JCAHO) or in compliance with equivalent
standards.
B. Conditions.
1. The benefits and services covered by this Rider are limited to the benefits and services set forth
herein which are Medically Necessary and are provided, prescribed, directed, approved, or approved
by HIP HEALTH PLAN and its Participating Providers, in accordance with the terms and conditions
of the Agreement.
2. The Premium for this Rider is set forth in the Binder and Agreement comprising part of the
Agreement. The terms and conditions regarding payment of the Premium for this Rider are as set
forth in the Agreement.
3. Nothing contained in this Rider shall be held to vary, alter, waive, supplement, or extend any of the
terms, conditions, provisions, agreements or limitations of the Agreement, other than as specifically
set forth below, and the provision of the Covered Services contemplated in this Rider shall be
governed by the terms and conditions of the Agreement.
4. Coverage under this Rider shall commence and terminate in accordance with the terms of the
Agreement.
5. If a Member incurs charges for any Covered Service provided under this Rider, other than a
required Co -payment, in order to receive reimbursement from HIP for the amount of the charge, a
claim must be submitted to HIP HEALTH PLAN as soon as reasonably practicable following the
date on which the Covered Service occurred, but in no event later than sixty (60) days after such
occurrence.
HIP FORM 50346
Fong
HEALTH PLAN OF FLORIDA HMO PLAN RIDER
C. Benefits and Limitations.
1. Inpatient Benefits. Inpatient benefits for Mental Health Conditions are limited to those Mental Health
Conditions which are determined by the Primary Care Physician, Referral Specialist or Mental Health
provider to be responsive to short-term treatment and not to be chronic or organic in nature.
2. Outpatient Benefits. The benefit shall consist of outpatient services for consultations, treatment,
evaluation and/or crisis intervention for Mental Health Conditions. To be Covered Services, such
services must be Medically Necessary and be provided by a physician, a psychologist licensed
pursuant to Chapter 490, Florida Statutes, a mental health counselor, marriage and family therapist,
or clinical social worker, in each case licensed pursuant to Chapter 491, Florida Statutes.
3. Partial Hospitalization Benefits. Partial Hospitalization benefits are limited to the treatment of mental
health conditions which are deemed by the Primary Care Physician and Referral Specialist to be
responsive to short term treatment and not to be chronic or organic in nature. In any benefit year,
if Partial Hospitalization services or a combination of inpatient and partial hospitalization are utilized,
the total benefits paid shall not exceed the cost of the number of days of inpatient benefits for
psychiatric services, including physician fees (based on physician fees which are usual and
customary in the community).
The benefits available to members hereunder shall not include coverage for treatment pursuant to
voluntary or involuntary confinement under Florida's Baker Act, Florida Statutes 394.451-394.4789,
whether such confinement is considered to be routine or an Emergency, except within the limits of
Paragraphs C (1) and C(2) above.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP 50346 11 /96
(R2HMEN)
01 /99
HEALTH PLAN OF FLORIDA
HIP HEALTH PLAN OF FLORIDA
VISION CARE RIDER
One pair each calendar year from the HIP Standard Collection at a participating
provider:
$29
Frame and Plastic Single Vision Lenses
$49
Frame and Plastic Bifocal Lenses (FT 25 - 35 or Executive Lenses)
$59
Frame and Plastic Trifocal Lenses (FT 25 - 35 or Executive Lenses)
The following lens options are available:
Progressive No Line Bifocals and Trifocals
$95
Lenticular
$95
High Index Plastic
$50
Polycarbonate
$30
Glass
$10
Photo Chromatic
$20
Tints
$10
UV Coating
$12
Scratch Coating
$15
Transitions
$70
Polarized
$45
Anti -Reflective Coating
$36
All the terms, conditions, limitations and exclusions of your Certificate of Coverage apply to the benefits
provided by this Rider.
HIP HEALTH PLAN OF FLORIDA, INC.
Daniel T. McGowan
President
118011
DEPENDENT STUDENT RIDER
HEALTH FLAN OF FLORIDA
In consideration of the payment of all applicable Premiums, the HIP Group Master Contract and Certificate
or Loverage are nereby amended and supplemented by the terms and conditions of this Rider.
Section II - ELIGIBILITY is amended to read:
B. Eligible Dependents. Subject to the limitations set forth in Section IV of this AGREEMENT, to be eligible
to enroll as a Dependent and remain covered as a Dependent, a person must live or work in the Service Area
(unless the Dependent is a full-time student enrolled in a school outside of the Service Area) and be:
3. A Subscriber's unmarried, dependent child age nineteen (19) through twenty-five (25) who is a student
attending an accredited, recognized institution of higher learning (an accredited university, college, secondary
school or trade school). To qualify, the student must attend school on a full-time basis defined as matriculated
and enrolled for a minimum of twelve (12) credit hours during each semester. Full-time student Dependents
while living outside the Service Area are covered for Emergency services only. For full Coverage, the student
must return to the Service Area. Eligibility under this provision shall remain in effect until the last day of the
year of the dependent student's twenty-fifth (25th) birthday. Proof, reasonably satisfactory to HIP, of a
Dependent student's eligibility status must be provided to HIP not later than thirty-one (31) days after each six
month anniversary from the time of enrollment of the Member, otherwise Coverage will be terminated.
1 . All terms used in this Rider shall have the respective meanings specified in the Group Master Contract and
Certificate of Coverage (the Agreement), unless the context otherwise requires.
2. The Premium for this Rider is set forth in the Binder and Agreement comprising a part of the Agreement.
The terms and conditions regarding payment of the Premium for this Rider are as set forth in the
Agreement with the GROUP.
3. Nothing herein contained shall be held to vary, alter, waive, supplement, or extend any of the terms,
conditions, provisions, agreements or limitations of the Group Master Contract or Certificate of Coverage
to which this Rider is attached and the provision of Covered Services contemplated by this Rider shall be
governed by the terms and conditions of the Agreement.
4. Coverage under this Rider shall commence and terminate in accordance with the terms of the Agreement.
This Amendment will be effective as of the Effective Date of the Certificate to which it is attached.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP 40084-DEPAGE (03/97)
f
HIP INSURANCE COMPANY OF FLORIDA
POINT OF SERVICE (POS) PLAN 21$*
BENEFIT AND PAYMENT SUMMARY
BENEFIT
REFERRED
Peecert
'"NON -REFERRED
Preauthorization required from PCP for all
Required
services EXCEPT emergencies & PCP office
visit
Deductible: Single/Family
No
No
$250/750
Out of Pocket Maximum Per Calendar Year
$1,500/3,000
No
$1000/3000
Maximum Lifetime Benefit
No
No
$1,000,000
Physician Visits:
Primary
100% after $10 co -pay
No
80% of UCR after Deductible
Specialists
100% after $20 co -pay
No
80% of UCR after Deductible
Annual Well Woman Exam
100% after $20 co -pay
No
80% of UCR after Deductible
Hospitalization:
A. Pre -Certified
Yes
80% Co-insurance after a
100% after $200 co -pay
Deductible of $500 per admission
B. Not Precertified
per admission
60% Co-insurance after a Deductible
No
of $500 per admission
Maternity Services:
A. OB Office visits
100% after $10 co -pay
No
80% of UCR after Deductible
B. Labor & Delivery services
100% after $200 co -pay
Yes
80% Co-insurance after a
per admission
Deductible of $500 per admission
No
60% Co-insurance after a Deductible
of $500 per admission
Inpatient Rehab (30 days per calendar year)
100%
Yes
80% of UCR after Deductible
No
60% of UCR after Deductible
Outpatient Services:
Facility Charges if Admitted
See Inpatient Schedule
A. Invasive Diagnostic Procedure
100%
No
80% of UCR after Deductible
B. All Other Diagnostic Therapeutic Procedures
100%
No
80% of UCR after Deductible
C. Outpatient Surgery
100%
Yes
80% of UCR after Deductible
No
60% of UCR after Deductible
D. Tubal Ligation and Vasectomies
100%
No
80% of UCR after Deductible
E. Emergency Room
100% after $50 co -pay if not admitted
No
70% of UCR after Deductible if not
admitted and determined not to be a
100% if admitted
true medical emergency according to
HIP's emergency medical criteria
Outpatient Rehabilitation Therapy:
100% after $20 co -pay
Physical, Occupational and Speech (not to exceed a
(20 visits /episode)
No
80% of UCR after Deductible
total of 80 visits per year 20 visits perepisode)
Durable Medical Equipment (DME):
100% after $25 co -pay
No
50% of UCR after Deductible
$5,000 annual maximum
Home Health:
100%
No
80% of UCR after Deductible
(20 visits /episode)
maximum of 40 visits or $1000 per
calendar year, whichever comes first
Hospice:
100%
Yes
80% Co-insurance after a
(210 days maximum per lifetime)
No
Deductible
60% Co-insurance after a Deductible
Skilled Nursing Facility
(limited to 30 days per calendar year)
100%
Yes
80% of UCR after Deductible
No
60% of UCR after Deductible
Infertility
Covered for Diagnostic Test Only
Not Covered
[Transplants
100% after $200 per admission
Not Covered
" Point of Service means you can choose any HIP/HMO provider, with a referral from your Primary Care Physician (referred); or any
provider you wish, without a referral from your Primary Care Physician (non -referred).
This is only a summary of the Point -of -Service Benefits. Please refer to the Certificates of Coverage and Member Guidebook for
complete details on the plan. Non -referred benefits underwritten by HIP Insurance Company of Florida
HIPIC FORM# 3002 7/97 (P2S218 - HIPIC)
N
HEALTH PLAN OF FLORIDA
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
Generic Drugs
Brand Name Drugs (If no generic equivalent is available or permitted by law.)
Contraceptives
Infertility Drugs
Limited to a 30-day supply (or 120 units) each time a prescription order is filled. When a
Member is expected to be absent from the Service Area and when pre -approved by HIP, up
to a 90-day supply may be obtained at one time.
Generic Drugs
Brand Name Drugs
Contraceptives
Infertility Drugs
A 90-day supply is covered each time a prescription order is filled. (The HIP physician must
prescribe a 90-day supply. Refills cannot be combined to obtain a 90-day supply.)
,,
The following drugs are not covered:
r1GIG1 W OGI..LIIAI %r, 1OW11 L 1U1 L U-PCIYIIICIIL It JLUJLAIUllb 0114 IIIIIILdlIU115.
$5
$101
$5
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
HIP 50338 03/97 01/98
(R2SRCG)
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
HEALTH PLAN OF FLORIDA
A. Definitions. All terms used in this Rider shall have the respective meanings specified in the Group Master
Contract and Certificate of Coverage, unless the context otherwise requires. Further, as used in this Rider:
"Covered Drugs" shall mean any legend Drug that is included in the HIP Drug Formulary and is dispensed by
a Participating Pharmacy according to a Prescription Order. Covered Drugs includes contraceptive, infertility
and impotency medications only if so indicated in Section I and II above. Covered Drugs excludes those drugs
indicated as Exclusions in Section III above. Covered Drugs includes any medication compounded by a
Participating Pharmacy according to a Prescription Order whose components includes drugs included in the HIP
Drug Formulary.
"HIP Drug Formulary" shall mean the listing of all prescription drugs approved for use by HIP.
"Legend Drug" shall mean any medicinal substance which the Federal Food, Drug and Cosmetic Act requires
to be labeled "Caution Federal Law prohibits dispensing without a prescription."
"Participating Pharmacy" shall mean a pharmacy contracted with HIP as a Participating Provider.
"Prescription Order" shall mean a written or oral request for Covered Drugs to a Participating Pharmacy (except
in the event of an Emergency while the Member is out of the Service Area, in which event the Prescription
Order need not be given to a Participating Pharmacy) by an HIP physician.
B. Conditions.
1. The benefits and services covered by this Rider are limited to the benefits and services set forth herein
which are provided, prescribed, directed, or approved by HIP and its Participating Providers.
2. The Premium for this Rider is set forth in the Binder and Agreement comprising part of the Agreement. The
terms and conditions regarding payment of the Premium for this Rider are as set forth in the Agreement.
3. Nothing contained in this Rider shall be held to vary, alter, waive, supplement, or extend any of the
terms, conditions, provisions, agreements or limitations of the Agreement, other than as specifically set
forth below, and the provision of the Covered Services contemplated in this Rider shall be governed by
the terms and conditions of the Agreement with the Group.
4. Coverage under this Rider shall commence and terminate in accordance with the terms of the Agreement.
C. Coverage. Coverage for Covered Drugs shall be provided subject to the following:
1 . Coverage for Covered Drugs shall be provided only when dispensed in accordance with HIP's Drug
Formulary and obtained from an HIP Participating Pharmacy pursuant to a Prescription Order made by an
HIP physician, except in the event of an Emergency condition arising while the Member is out of the
Service Area;
2. Member shall be responsible for one Co -payment for each prescription or refill; Participating Pharmacies
will dispense only generic equivalent Covered Drugs when such generic equivalents are available and
allowed by law unless the prescribing physician deems the use of the brand name Covered Drug to be
Medically Necessary and indicates the same on the prescription form. In such a case, the physician
must obtain prior approval from HIP. When prior approval is obtained by the physician from HIP, the
Member is not required to pay the cost difference between the generic and brand product;
Except as provided above, if the Member or the Member's physician requests a brand name drug when
a therapeutic equivalent generic drug is available and permitted by law, the Member shall be responsible
HIP 50338 03/97 01 /98
(R2SRCG)
PRESCRIPTION DRUG RIDER SCHEDULE OF CO -PAYMENTS
HIMTH PLAN► OF FLORIDA
for paying the brand Co -payment plus the cost difference between the brand and generic product.
3. Member shall be responsible to pay the full cost incurred for: a) any drug not included in HIP's Drug
Formulary when approval is not obtained by the physician, b) any drug not approved by HIP when pre -
approval is required but not obtained;
4. When Member obtains a Covered Drug from a Participating Pharmacy at a time when Member does not
have the identification card available, Member shall pay for the full cost of the Covered Drug and will be
required to submit the receipt for same together with an appropriate claim form to HIP for
reimbursement, less applicable Co -payments. Member will not be reimbursed more than HIP's
contracted amount for drugs dispensed with Participating Pharmacies;
5. If you are going on vacation or planning on being out of the Service area, then you need to obtain the
appropriate medication supply to take with you. You may request up to a 90-day vacation supply. This
is important because maintenance medications will ONLY be covered when you are utilizing the
Interplan Services. In addition, when utilizing the Interplan services, you are still encouraged to obtain
your medications at your local participating pharmacy before leaving the Service area. This will allow
you to avoid having to pay the full cost of the medication and then submitting for reimbursement. You
should contact the Customer Service Department to obtain information regarding what participating
pharmacies are available in the Interplan Program.
If you are out of the service area and are not in one of our Interplan areas, then ONLY medications
required for emergency care would be covered.
6. Medications obtained in association with required emergency care is covered so long as they are
covered under your benefit plan. You should contact the Customer Service Department for information
regarding available pharmacy locations outside of the service area. The utilization of these pharmacies
will enable you to pay for the prescription according to your benefit plan. If the area you are visiting
does not have a participating pharmacy available, for reimbursement submit the itemized receipt along
with a reimbursement form to the claims department.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP 50338 03/97 01/98
(R25RCG)
HOW
HEALTH PLAN OF PLORICA
HIP INSURANCE COMPANY OF FLORIDA
PRESCRIPTION DRUG RIDER
This Rider is attached to and made a part of the Certificate. This Rider is subject to all the provisions --including
the Schedule of Insurance and the General Limitations --contained in the Certificate, to the extent they are not in
direct conflict with the following:
The Company will pay for Expenses Incurred by the Member for drugs and medicines, subject to the following
provisions:
1. The drugs and medicines are lawfully obtainable only upon a Physician's written prescription.
2. The Deductible to be paid at the time the prescription or refill is filled is 40% of Usual, Reasonable and
Customary charges per filled or refilled prescription or $5.00, whichever is more.
This Deductible will not apply toward satisfaction of the Major Medical Deductible or the Out-of-pocket
Maximum.
3. The dispensing limit per filled or refilled prescription will be the lesser of: a) a 34-day supply; or b) 100
units.
EXCLUSIONS: the group Policy does not cover:
1. injectables
2. therapeutic devices
3. immunosuppressants
4. Rogaine
5. nicorette
B. diabetic supplies. This does not apply to insulin.
7. growth hormones.
8. over-the-counter drugs and supplies,
9. drugs or medicines that are payable under any other benefit of the group Policy.
10. refills in excess of the number specified by the Physician or refills dispensed after one (1) year from the
Physician's order.
11. Retin A, as a treatment for photo aging for an Insured Person or Insured Dependent who is age twenty-
six (26) or older.
12. Mail Order prescription drugs.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP HEALTH PLAN OF FLORIDA, INC.
Daniel T. McGowan
President
HIPIC POS RX RIDER (R2SRCG-OON1) 07/97
HMO PLAN RIDER
HIALTH PLAN OF FLORIDA
A. Inpatient services (limited to 30 days per calendar year). 1 $50 copay per day
B. Outpatient services (limited to 20 visits per calendar year). 1 $0 copay per visit
In consideration of the payment of all applicable Premiums, the HIP HEALTH PLAN Group Master Contract
is hereby amended and supplemented by the terms and conditions of this Rider.
C. Benefits and Limitations.
1. Inpatient Benefits. Inpatient benefits for Mental Health Conditions are limited to those Mental Health
Conditions which are deemed by the Primary Care Physician and Referral Specialist to be responsive
to short-term treatment and not to be chronic or organic in nature.
Outpatient Benefit. The benefit shall consist of outpatient services for consultations, treatment,
evaluation and/or crisis intervention for Mental Health Conditions. To be Covered Services, such
services must be Medically Necessary and be provided by a physician, a psychologist licensed pursuant
to Chapter 490, Florida Statutes, a mental health counselor, marriage and family therapist, or clinical
social worker, in each case licensed pursuant to Chapter 491, Florida Statutes, upon referral by a
Primary Care Physician.
2. Partial Hospitalization Benefits. Partial Hospitalization benefits are limited to the treatment of mental
health conditions which are deemed by the Primary Care Physician and Referral Specialist to be
responsive to short term treatment and not to be chronic or organic in nature. In any benefit year, if
Partial Hospitalization services or a combination of inpatient and partial hospitalization are utilized, the
total benefits paid shall not exceed the cost of the number of days of inpatient benefits for psychiatric
services, including physician fees (based on physician fees which are usual and customary in the
community).
3. The benefits available to members hereunder shall not include coverage for treatment pursuant to
voluntary or involuntary confinement under Florida's Baker Act, Florida Statutes 394.451-394,4789,
whether such confinement is considered to be routine or an Emergency, except within the limits of
Paragraphs C(1) and C(2) above.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP FORM 50346 11/96 1/98
(R2SMEN)
HIP INSURANCE COMPANY OF FLORIDA
MENTAL HEALTH & NERVOUS CONDITIONS RIDER
Subject to all the provisions of the Group Policy, benefits payable for all Expenses Incurred in connection
with mental illness are as follows:
1. Covered Expenses for treatment, services or supplies otherwise covered under the Group Policy if
received during a Hospital confinement will reduce the Maximum Individual Benefit shown in the Schedule
of Insurance as applicable to All other Covered Expenses. The Maximum Calendar Year Benefit shall be
30 days. The Maximum Calendar Year Benefit shall be subject to the applicable Deductible and
Percentage Payable as shown in the Schedule of Insurance.
2. Covered Expenses for treatment, services, or supplies otherwise covered under the Group Policy if
received during Partial Hospitalization will reduce the Maximum Benefit shown in the Schedule of
Insurance as applicable to All other Covered Expenses. The Maximum Calendar Year Benefit shall be
the cost of 30 days of Hospital Confinement for mental illness treatment, services, or supplies; in any
calendar year this 30-day maximum shall be reduced day -for -day by the number of days for which
benefits under item 1 above are paid or payable in that calendar year. Partial Hospitalization means a
program accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or a
similar organization. It also includes: a) alcohol rehabilitation programs. The Maximum Calendar Year
Benefit shall be subject to the applicable Deductible and Percentage Payable as shown in the Schedule of
Insurance.
3. Covered Expenses for outpatient mental illness treatment or services will reduce the Maximum
Individual Benefit shown in the Schedule of Insurance as applicable to all other Covered Expenses. The
Maximum Calendar Year Benefit (for all providers combined regardless of whether they are Participating
or Nonparticipating) shall be 20 visits. The treatment or services must be in the form of consultations.
The provider must be: a) a Florida -licensed Doctor of Medicine; b) a Florida -licensed psychologist; c) a
Florida- licensed mental health counselor; d) a Florida -licenses marriage and family therapist; or e) a
Florida -licensed clinical social worker. The Maximum Calendar Year Benefit shall be subject to the
applicable Deductible(s) and Percentage Payable as shown in the Schedule of Insurance.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP Insurance Company of Florida
Daniel T. McGowan
President
HIPIC-POS-MEN (R2SMEN-OON1) 07/97
HEALTH PLAN OF FLORIDA
A. Inpatient services (limited to 30 days per calendar year). 1 $50 copay per day
B. Outpatient services (limited to $2,000 per calendar year). $0 copay per visit;
HIP pays no more
than $35 per visit
COMBINED LIFETIME MAXIMUM OF $4,500 FOR INPATIENT AND OUTPATIENT
SERVICES
In consideration of the payment of all applicable Premiums, the HIP HEALTH PLAN Group Master Contract
is hereby amended and supplemented by the terms and conditions of this Rider.
C. Benefits and Limitations.
1. Inpatient Benefits. Inpatient benefits for Mental Health Conditions are limited to those Mental Health
Conditions which are deemed by the Primary Care Physician and Referral Specialist to be responsive
to short-term treatment and not to be chronic or organic in nature.
Outpatient Benefit. The benefit shall consist of outpatient services for consultations, treatment,
evaluation and/or crisis intervention for Mental Health Conditions. To be Covered Services, such
services must be Medically Necessary and be provided by a physician, a psychologist licensed pursuant
to Chapter 490, Florida Statutes, a mental health counselor, marriage and family therapist, or clinical
social worker, in each case licensed pursuant to Chapter 491, Florida Statutes, upon referral by a
Primary Care Physician.
2. Partial Hospitalization Benefits. Partial Hospitalization benefits are limited to the treatment of mental
health conditions which are deemed by the Primary Care Physician and Referral Specialist to be
responsive to short term treatment and not to be chronic or organic in nature. In any benefit year, if
Partial Hospitalization services or a combination of inpatient and partial hospitalization are utilized, the
total benefits paid shall not exceed the cost of the number of days of inpatient benefits for psychiatric
services, including physician fees (based on physician fees which are usual and customary in the
community).
3. The benefits available to members hereunder shall not include coverage for treatment pursuant to
voluntary or involuntary confinement under Florida's Baker Act, Florida Statutes 394.451-394.4789,
whether such confinement is considered to be routine or an Emergency, except within the limits of
Paragraphs C(1) and C(2) above.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
1IIP FORM 50347 11/96 1/98
R2SADD
HIP INSURANCE COMPANY OF FLORIDA
ALCOHOL & SUBSTANCE ABUSE RIDER
Subject to all the provisions of the Group Policy, benefits payable for all Expenses Incurred on
an inpatient and outpatient basis in connection with alcoholism and drug dependency are as
follows:
1. All expenses must be incurred in connection with an intensive treatment program. The
expenses shall be incurred: a) for services rendered by, under the supervision of, or
prescribed by a Florida -licensed Doctor of Medicine or a Florida -licensed psychologist;
or b) in a program accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or Florida -approved.
2. The Maximum Individual Benefit for all expenses shall be $2,000 within which shall be a
maximum of 30 outpatient visits with a maximum benefit payable of $35.00 per visit.
Outpatient benefits will not be payable for detoxification. Inpatient and Outpatient
benefits shall be subject to the applicable Deductible(s) and Percentage Payable as
shown in the Schedule of Insurance.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP Insurance Company of Florida
Daniel T. McGowan
President
HIPIC-POS-ALC/SA (R2SADD-00N1) - 07/97
HMO PLAN RIDER
HEALTH PLAN OF FLORIDA
A. Inpatient services (limited to 30 days per calendar year).
B. Outpatient services (limited to $2,000 per calendar year).
COMBINED LIFETIME MAXIMUM OF $4,500 FOR INPATIENT AND OUTPATIENT
SERVICES
$50 copay per day
$0 copay per visit;
HIP pays no more
than $35 per visit
In consideration of the payment of all applicable Premiums, the HIP HEALTH PLAN Group Master Contract
is hereby amended and supplemented by the terms and conditions of this Rider.
C. Benefits and Limitations.
1. Inpatient Benefits. Inpatient benefits for Mental Health Conditions are limited to those Mental Health
Conditions which are deemed by the Primary Care Physician and Referral Specialist to be responsive
to short-term treatment and not to be chronic or organic in nature.
Outpatient Benefit. The benefit shall consist of outpatient services for consultations, treatment,
evaluation and/or crisis intervention for Mental Health Conditions. To be Covered Services, such
services must be Medically Necessary and be provided by a physician, a psychologist licensed pursuant
to Chapter 490, Florida Statutes, a mental health counselor, marriage and family therapist, or clinical
social worker, in each case licensed pursuant to Chapter 491, Florida Statutes, upon referral by a
Primary Care Physician.
2. Partial Hospitalization Benefits. Partial Hospitalization benefits are limited to the treatment of mental
health conditions which are deemed by the Primary Care Physician and Referral Specialist to be
responsive to short term treatment and not to be chronic or organic in nature. In any benefit year, if
Partial Hospitalization services or a combination of inpatient and partial hospitalization are utilized, the
total benefits paid shall not exceed the cost of the number of days of inpatient benefits for psychiatric
services, including physician fees (based on physician fees which are usual and customary in the
community).
3. The benefits available to members hereunder shall not include coverage for treatment pursuant to
voluntary or involuntary confinement under Florida's Baker Act, Florida Statutes 394.451-394.4789,
whether such confinement is considered to be routine or an Emergency, except within the limits of
Paragraphs C(1) and C(2) above.
HIP HEALTH PLAN OF FLORIDA
Daniel T. McGowan
President
HIP FORM 50347 11/96 I/98
R2SADD
HIP INSURANCE COMPANY OF FLORIDA
ALCOHOL & SUBSTANCE ABUSE RIDER
Subject to all the provisions of the Group Policy, benefits payable for all Expenses Incurred on
an inpatient and outpatient basis in connection with alcoholism and drug dependency are as
follows:
All expenses must be incurred in connection with an intensive treatment program. The
expenses shall be incurred: a) for services rendered by, under the supervision of, or
prescribed by a Florida -licensed Doctor of Medicine or a Florida -licensed psychologist;
or b) in a program accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or Florida -approved.
2. The Maximum Individual Benefit for all expenses shall be $2,000 within which shall be a
maximum of 30 outpatient visits with a maximum benefit payable of $35.00 per visit.
Outpatient benefits will not be payable for detoxification. Inpatient and Outpatient
benefits shall be subject to the applicable Deductible(s) and Percentage Payable as
shown in the Schedule of Insurance.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP Insurance Company of Florida
Daniel T. McGowan
President
HIPIC-POS-ALC/SA (R2SADD-00N1) - 07/97
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
Individual Lifetime Maximum Benefit $2,000,000
Major Medical Expense Deductibles for Participating and
Non -Participating
Calendar Year Deductible For Each
Insured Person $300
Calendar Year Deductible For Each
Family of Insured Person $900
Out of Pocket Maximum
PAR/NON-PAR
$1,500
$3,000
Benefit Payable
Hospital
Deductible/Co-Payment
After Deductible/
Major Medical Expenses
Applicable
Co -Payment
Room and Board and Ancillary
Services at Semi -Private
Room Rate
-Participating Hospital
YES
90%
-Non-Participating Hospital
YES
70%
Outpatient Non -Surgical
Services
-Participating Hospital YES 90%
-Non-Participating Hospital YES 70%
(P2P971-001) 1 01/99
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
Benefit Payable
Hospital Deductible/Co-Payment After Deductible/
Major Medical Expenses Applicable Co -Payment
Outpatient Surgical Services
-Participating Hospital YES 90%
-Non-Participating Hospital YES 70%
Emergency Room Visit
(Facility Charge)
-Participating Hospital
YES
90%
-Non-Participating Hospital
YES
70%
Benefit Payable
Physician
Deductible/Co-Payment
After Deductible/
Major Medical Expenses
Applicable
Co -Payment
Hospital Visits
-Participating Physician
YES
90%
-Non-Participating Physician
YES
70%
Office Visits
-Participating Physician (1)
NO, $10 PER VISIT
100%
-Non-Participating Physician
YES
70%
Allergy Immunizations
-Participating Physician
YES
90%
-Non-Participating Physician
YES
70%
(1) Includes emergency room visits by the physician and minor diagnostic and therapeutic procedures
preformed in the physician's office.
(P2P971-001) 2 01/99
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
Benefit Payable
Physician
Deductible/Co-Payment
After Deductible/
Major Medical Expenses
Applicable
Co -Payment
Inpatient Surgical Services
-Participating Physician
YES
90%
-Non-Participating Physician
YES
70%
Outpatient Surgical Services
-Participating Physician
YES
90%
-Non-Participating Physician
YES
70%
Benefit Payable
Deductible/Co-Payment After Deductible/
Major Medical Expenses Applicable Co -Payment
Pre -Admission Testing in
Accordance with Group Policy
Provisions NO 100%
Second Surgical Opinion in
Accordance with Group Policy
Provisions NO 100%
Mental and Nervous Disorders/
Alcoholism and Drug Dependency/
Inpatient Care
-Participating Hospital MH Inpatient Maximum:
31 days per calendar year
SA Inpatient Maximum:
31 days 90%
-Non-Participating Hospital YES 70%
(P2P971-001) 3 01 /99
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
Benefit Payable
Deductible/Co-Payment
After Deductible/
Major Medical Expenses
Applicable
Co -Payment
Mental and Nervous Disorders/
Alcoholism and Drug Dependency/
Outpatient Care
-Participating Hospital
MH Outpatient Maximum:
limited to 30 visits per calendar
year.
SA Outpatient Maximum:
limited to $1,540 per calendar
year.
90%
-Non-Participating Hospital
YES
70%
Skilled Nursing Facility Services
(unlimited days)
-Participating
YES
90%
-Non-Participating
YES
70%
Home Health Care Services
(unlimited days)
-Participating
YES
90%
-Non-Participating
YES
70%
Durable Medical Equipment
-Participating Supplier
YES
90%
-Non-Participating Supplier
YES
70%
Emergency Ambulance Service
-Participating
$25
90%
-Non-Participating
$25
70%
(P2P971-001) 4 01/99
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
Maior Medical Expenses
Chiropractic Services
-Participating
-Non-Participating
Generic Prescription Drugs
Deductible/Co-Payment
Applicable
YES
YES
-Participating Pharmacy $10 per prescription or refill
(Includes contraceptives)
-Non-Participating pharmacy $14 per prescription or refill
(Includes contraceptives)
Benefit Payable
After Deductible/
Co -Payment
90%
70%
100%
100%
Hospice are Services (limited to 180 days) PAR NON -PAR
-Inpatient YES 60 day max 60 day max
-Outpatient YES 90% 70%
All other provider medical services YES 90% 70%
Services/Supplies not available at
a participating provider YES 90% 70%
Member and dependents who live
outside the service area SEE SCHEDULE FOR PERSONS
RESIDING OUTSIDE THE SERVICE AREA
PRIOR APPROVAL PENALTY 20%
If prior approval is not obtained when required, or obtained but not followed, the Percentages
payable will be reduced by 20%. These reductions will not apply toward satisfaction of a
Deductible, Copayment or Out -of -Pocket Maximum.
(P2P971-001) 5 01 /99
HIP Insurance Company of Florida
Schedule of Benefits
Plan 971
Preferred Provider Organization (PPO) Product
FOR PERSONS RESIDING OUTSIDE THE SERVICE AREA
Individual Lifetime Maximum Benefit $1,000,000
Major Medical Expense Deductibles PAR
Calendar Year Deductible For Each
Insured Person $200
Calendar Year Deductible For Each
Family of Insured Persons $400
All covered expenses 90%
Emergency care 90%
Drugs and medicines 90%
Prior Approval penalty 20%
If prior approval is not obtained when required, or obtained but not followed, the Percentages
payable will be reduced by 20%. These reductions will not apply toward satisfaction of a
Deductible, Copayment or Out -of -Pocket Maximum.
(P2P971-001) 6 01 /99
HIP Insurance Company
300 South Park Road
Hollywood, Florida 33023
RIDER
This Rider is attached to and made a part of the Certificate. The benefits provided by this rider apply to the
extent they are greater than those shown in the Certificate. This Rider is subject to all the provisions, including
the General Limitations, contained in the Certificate to the extent they are not in direct conflict with the following:
PRESCRIPTION DRUG BENEFIT
DEFINITIONS
FORMULARY: Means a list of drug products, including their strengths and appropriate dosages that are
available for use by Insured Persons and Insured Dependents.
NON -FORMULARY: Means prescription drugs not on HIP's Formulary.
NONPARTICIPATING PHARMACY: Means a Pharmacy that has not entered into a service agreement with the
Company.
PARTICIPATING PHARMACY: Means a Pharmacy which agrees to provide service under the terms set forth
by the Company.
PHARMACY: Means a licensed establishment where prescription medications are dispensed by a Pharmacist.
PRESCRIPTION: Means a direct order for the preparation and use of a drug, medicine or medication. This
order may be given by a Physician to a Pharmacist for the benefit of and use by an Insured Person or Insured
Dependent. The drug, medicine or medication must be obtainable only by Prescription. The Prescription may
be given to the Pharmacist verbally or in writing by the Physician. The Prescription must include:
1. the name of the Insured Person or Insured Dependent for whom the Prescription is intended;
2. the type and quantity of the drug, medicine or medication prescribed, and the directions for its use;
3. the date the Prescription was prescribed; and
4. the name, address and DEA number of the prescribing Physician.
BENEFIT DESCRIPTION
Benefits are payable if covered Prescription drugs are received by the Insured Person or Insured Dependent
while he or she is insured for this benefit. The amount of the benefit provided is as follows:
1. For Prescriptions filled at Participating Pharmacies - the sum of a, b and c below, minus the Insured
Person's or Insured Dependent's Deductible and copayment, if any:
a. the wholesale ingredient cost, as determined by the Company;
b. the professional dispensing fee, as determined by the Company;
c. any state sales tax.
Your ID card must be presented to a Participating Pharmacy each time a Prescription is filled or refilled.
2. For Prescriptions filled at Nonparticipating Pharmacies and with claims submitted directly to the Company by
the Insured Person or Insured Dependent - the actual charge made by the Pharmacy minus the Insured
Person's or Insured Dependent's copayment.
R2PRC 1
I�.
PRESCRIPTION DRUG COPAYMENT
The Prescription drug copayment is $10 at a Participating Pharmacy and $14 at a Non -Participating Pharmacy.
It must be met each time a Prescription is filled or refilled. The Prescription drug copayment is not covered by
this or any other benefit under the Group Policy. Contraceptives are included.
In addition to the copayment, the Insured Person or Insured Dependent must pay the Participating Pharmacy
100% of the additional cost for a more expensive brand name Prescription drug, which is dispensed at the
request of the Insured Person or Insured Dependent or the prescribing Physician, when a generic is available.
The additional cost for a more expensive brand name Prescription drug obtained at a Nonparticipating
Pharmacy is not covered if it is dispensed at the request of the Insured Person or Insured Dependent or the
prescribing Physician, when a generic is available.
Any expenses incurred under provisions of this benefit do not apply toward the Insured Person's or Insured
Dependent's Deductible or Out -of -Pocket Maximum under the Schedule of Insurance/Benefit Summary.
Covered Expenses will be applied toward the Maximum Individual Benefit provision under the Schedule of
Insurance.
COVERED PRESCRIPTION DRUGS
Covered Prescription drugs are:
1. any drug, medicine or medication that, under federal or state law, may be dispensed only by Prescription
from a Physician, or any compounded Prescription containing such drug, medicine or medication; and
2. insulin on Prescription.
Covered Prescription drugs must:
1. be prescribed by a Physician for the treatment of an Injury or Sickness;
2. be dispensed by a Pharmacist;
3. be a generic medication when both a generic and a more expensive brand name drug are immediately
available;
Contrary to any provisions of the Group Policy, Prescription drug expenses covered under this benefit are not
covered under any other provision of the Group Policy. Any amount in excess of the maximum amount provided
under this benefit is not provided under any other provision of the Group Policy.
EXCLUSIONS FROM THIS BENEFIT
No benefit is provided for:
1. any drug, medicine or medication that is consumed at the place where the Prescription is given, or that is
dispensed by a Physician;
2. any portion of a Prescription or refill that exceeds a 34-day supply or a 120 unit dose, whichever is less;
except that a vacation supply of up to 90 days (at 3 times the copayment specified above) may be
obtained upon Prescription;
3. Refills in excess of the number specified by the Physician or dispensed more than one year from the date
of the Physician's original order;
4. the administration of covered medication;
5. Prescriptions that are to be taken by or administered to the Insured Person or Insured Dependent, in
whole or in part, while he or she is a patient in a Hospital, rest home, sanitarium, skilled nursing facility,
convalescent hospital, inpatient Hospice facility or other facility where drugs are ordinarily provided by the
facility on an inpatient basis.
6. Prescriptions that may be properly received without charge under local, state or federal programs,
including Workers' Compensation;
R2PRC 1
HIP Insurance Company of Florida
300 South Park Road
Hollywood, Florida 33023
ALCOHOL AND SUBSTANCE ABUSE BENEFIT
RIDER
This Rider is attached to and made a part of the Certificate. The benefits provided by this rider apply to
the extent they are greater than those shown in the Certificate. This Rider is subject to all the provisions,
of the Group Policy, including the General Limitations, contained in the Policy to the extent they are not
in direct conflict with the following:
All expenses must be incurred in connection with an intensive treatment program. The expenses
shall be incurred: a) for services rendered by, under the supervision of, or prescribed by a
Florida -licensed Doctor of Medicine or a Florida -licensed psychologist; or b) in a program
accredited by the Joint Commission on Accreditation of Hospitals (JCAH) or Florida -approved.
The Hospital must be accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or a similar organization and the admission must be precertified.
2. Covered Expenses for outpatient substance abuse treatment or services will reduce the Maximum
Individual Benefit shown in the Summary of Benefits as applicable to all other Covered
Expenses. The Maximum Calendar Year Benefit (for all providers combined regardless of
whether they are Participating or Nonparticipating) shall be 35 (thirty-five) visits per calendar
year. The treatment or services must be in the form of consultations. The provider must be a
licensed physician, psychologist, clinical social worker or other clinician licensed to provide
outpatient substance abuse services. Outpatient benefits will not be payable for detoxification.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP INSURANCE COMPANY OF FLORIDA
Daniel T. McGowan
President
R2PAD3 RV. 11/05/1999
r
HIP Insurance Company of Florida
300 South Park Road
Hollywood, Florida 33023
MENTAL HEALTH BENEFIT
RIDER
This Rider is attached to and made a part of the Certificate. The benefits provided by this rider apply to the extent
they are greater than those shown in the Certificate. This Rider is subject to all the provisions, of the Group Policy,
including the General Limitations, contained in the Policy to the extent they are not in direct conflict with the
following:
Inpatient Covered Expenses for inpatient treatment, services, or supplies otherwise covered under the
Group Policy if received in a Hospital will reduce the Maximum Individual Benefit shown in the Summary
of Benefits as applicable to all other Covered Expenses. The Maximum Calendar year Benefit shall be 31
days. The Hospital must be accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or a similar organization and the admission must be precertified.
2. Covered Expenses for treatment, services, or supplies otherwise covered under the Group Policy if
received during Partial Hospitalization will reduce the Maximum Individual Benefit shown in the Schedule
of Insurance as applicable to all other Covered Expenses. Partial Hospitalization means outpatient
treatment, services, or supplies provided by a duly licensed program which is accredited by the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) or a similar organization. Partial
Hospitalization shall be available in lieu of Hospital confinement on the basis that each inpatient day equals
two (2) Partial. Hospitalization days. Partial hospitalization must be precertified.
Covered Expenses for outpatient mental health treatment or services will reduce the Maximum Individual
Benefit shown in the Summary of Benefits as applicable to all other Covered Expenses. The Maximum
Calendar Year Benefit (for all providers combined regardless of whether they are Participating or
Nonparticipating) shall be 35 (thirty-five) visits per calendar year. The treatment or services must be in the
form of consultations. The provider must be a licensed physician, psychologist, mental health counselor,
clinical social worker or other clinician licensed to provide outpatient mental health services.
Except as provided above, all provisions, limitations, or exclusions shown in the Group Policy apply to these
provisions.
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP INSURANCE COMPANY OF FLORIDA
Daniel T. McGowan
President
R2PMH3 7/99
7. any drug, medicine or medication labeled "Caution - Limited By Federal Law To Investigational Use: " or
any experimental drug, medicine or medication, even though a charge is made to the Insured Person or
Insured Dependent;
8. dietary and nutritional supplements;
9. vitamins, except Legend prenatal vitamins. Legend vitamins used for the treatment of renal
disease,hypoparathyroidism or other Medically Necessary conditions when prescribed by a Physician
may be covered with prior approval;
10. injectable drugs (except prescribed Insulin, Imitrex, Epi-pen, Epi-pen Jr and Interferon products used for
the treatment of multiple sclerosis);
11. syringes and needles (except when prescribed for the treatment of diabetes);
12. drugs used to treat impotency;
13. biological serum;
14. experimental drugs or drugs not approved by the U.S. Food and Drug Administration;
15, Retin A (except when prescribed for Acne Vulgaris);
16. any drug or medicine that is lawfully obtainable without a Prescription, with the exception of insulin;
17. diet pills and drugs for the treatment of obesity, including all Anorexiants;
18. drugs which are not Medically Necessary or are for cosmetic purposes, including drugs for the treatment
of hair loss or baldness;
19. devices and appliances (except blood glucometers, test strips, lancets and spacers).
20. lost, stolen or destroyed medication(s);
(Note: Some drugs require prior approval prior to dispensing by a Participating Pharmacy).
This Rider will be effective as of the Effective Date of the Certificate to which it is attached.
HIP HEALTH PLAN OF FLORIDA, INC.
Daniel T. McGowan
President
R2PRC1