Members: Programs: Healthy Workers: Benefits and Services
This matrix is intended to be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage(
) should be consulted for a detailed description of coverage benefits and limitations.
|
Benefit |
Covered Services
|
Member Pays |
|---|---|---|
Deductible |
$0 | |
| Lifetime Maximum |
Unlimited | |
| Professional Services | In-licensed hospital, skilled nursing facility, hospice, mental health facility; office or home physician visit |
No co-payment |
| Outpatient |
Chemotherapy, dialysis, surgery, anesthesiology, radiation, and associated medically necessary facility charge |
No co-payment |
| Hospital Services | Room and board, general nursing care, ancillary services including operating room, intensive care unit, prescribed drugs, laboratory, and radiology during inpatient stay |
No co-payment |
| Emergency Health Coverage | 24-hour care for sudden, serious, and unexpected illness, injury, or condition requiring immediate diagnosis in and out of the Plan |
No co-payment if services are obtained at San Francisco General Hospital ; $20 co-payment at any other hospital emergency room |
| Ambulance Services |
Ambulance transportation when medically necessary |
No co-payment |
|
Prescription Drug Coverage |
Prescriptions drug are covered per the DPH Formulary. Call 1-800-777-0074 |
$5 co-payment per prescription for preferred drugs $10 co-payment per prescription for non-preferred drugs |
| Durable Medical Equipment | Equipment suitable for use in the home, such as blood glucose monitors, apnea monitors, asthma-related equipment, and supplies |
No co-payment |
|
Mental Health Services |
Inpatient (limited to 30 days per Benefit Year); other services provided through the local mental health department with referral. Please note that treatment for the diagnosis of severe emotional disturbances and severe mental illness are excluded from the benefits limitations |
No co-payment |
| Chemical Dependency Services - Inpatient |
Outpatient visits for crisis intervention (up to 20 per benefit year) |
$3/visit |
| Inpatient detoxification | No co-payment | |
| Crisis intervention and outpatient alcohol or drug abuse treatment as medically necessary (up to 20 visits) | No co-payment | |
| Home Health Services |
Medically necessary skilled care (not custodial); home visits, physical, occupational and speech therapy |
No co-payment |
| Hearing Aids/Services | Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs | No co-payment |
| Eye Exams/Supplies | Annual exams to determine the need for corrective lenses | $10 per eye exam $25 for frames under $75 every 24 months (Member is responsible for amount over $75) |
| Diagnostic X-ray and Laboratory Services |
Therapeutic radiological services, ECG, EEG, mammography, other diagnostic laboratory and radiology tests, laboratory tests for the management of diabetes |
No co-payment |
| Orthoses and Prostheses | Orthoses and prostheses as prescribed by SFHP providers | No co-payment |
| Transplants |
Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ |
No co-payment |
| Hospice |
Medically necessary skilled care; counseling, drugs and supplies; short-term inpatient care for pain control and system management; bereavement services, physical, speech and occupational therapies; medical social services short-term inpatient and respite care |
No co-payment |
| Rehabilitative Therapies - Inpatient | Physical, occupational, speech therapy | No co-payment |
| Rehabilitative Therapies - Outpatient | Physical, occupational, speech therapy as medically necessary | No co-payment |
| Health Education | Health education materials | No co-payment |
Note: There are no co-payments for preventive visits or for members under the age of 24 months for well-baby care and office visits. There are no co-payments for members who are documented Alaska Natives or Native Americans.
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