City & DERP Member Handbook 2019 - DHMO - V2
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City & DERP Member Handbook 2019 - DHMO - V2
DENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 of Benefits (Who Pays What)Prior authorization may be required for some services. Please refer to the prior authorization list, which can be found on our website at dcnY.cihe.aithm.c.diGQl£>lqn.org/p riQr_QutbQ0ZQttQn_li£t For questions about prior authorization, coll Health Plan Services at 303-60 City & DERP Member Handbook 2019 - DHMO - V2 2-2100 or toll-free at 1-800-700-8140 (TTY users call 711).If you l»ave a life or limb-threatening emergency, call 9-1-1 or go to the closest hospitalCity & DERP Member Handbook 2019 - DHMO - V2
emergency department or nearest medical facility You are not required to get a referral for emergency care and cost sharing IS the same in and out ofDENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 l FamilyD $500 per calendar year. II $1,b00 per calendar year. All individual deductible amounts will count toward the family deductible; an individual will not have to pay more than the individual deductible amount.c $750 per calendar year. 1 $1,/30 per calendar year. All individual deductible amou City & DERP Member Handbook 2019 - DHMO - V2 nts will count toward the family deductible; an individual will not have to pay more than the individual deductible amount.Not applicable.Out-of-PockoCity & DERP Member Handbook 2019 - DHMO - V2
t MaximumIndividual Family11 $3,000 per calendar year. D $6.000 per calendar year. The out-of pocket maximum includes the annual deductible, coinsuranDENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 ual deductible, coinsurance and copays It does not include monthly premiums.Not applicable.All individual out-of-pocket amounts will count toward the family out-of-pocket maximum; an individual will not have to pay more than the individual out-of-pocket maximumAll individual out-of-pocket amounts wi City & DERP Member Handbook 2019 - DHMO - V2 ll count toward the family out-of-pocket maximum; an individual will not have to pay more than the individual out-of-pocket maximum.Lifetime MaximumDCity & DERP Member Handbook 2019 - DHMO - V2
No lifetime maximum.[I No lifetime maximum.Not applicable.Covered ProvidersD Denver Health and Hospital Authority providers and facilities. Columbine DENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 do I lospital, Colorado Pediatric Partners and Children’s Hospital Colorado providers and facilities. Cofinity network providers and facilities. Columbine network tor chiropractic. See online provider directory for a complete list of current providers; dcnvcrhcalthmcdicalplan.orgNot applicable.Medic City & DERP Member Handbook 2019 - DHMO - V2 al Office VisitsPrimary Care Providers (Family Medicine, Internal Medicine and Pediatrics)D $25 copay per visit In addition to the visit copayment, thCity & DERP Member Handbook 2019 - DHMO - V2
e applicable copayment and any deductible/ coinsurance applies for additional services.c $30 copay per visit. In addition to the visit copayment, the DENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 .Not covered.This is a summary of the most frequently asked about benefits. This chart dees not explain benefits, cost share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost share amounts. For a complete explanation, please refer to the •'Benefits/Coverage City & DERP Member Handbook 2019 - DHMO - V2 (What is Covered)" and "Limitations and Exclusions (What is not covered)'' sections.Questions? Call Health Plan Services at 303-602-2100 or toll freeCity & DERP Member Handbook 2019 - DHMO - V2
at 1-800-700-8140 (TTY users should call 711)31. Schedule of Benefits (Who Pays What)Denver Health NetworkHighpoint & Cofinity NetworkOut of NetworkPrDENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 reventive Services Task Force (USPSTF). Annual well visit, well woman exams, well baby care, prenatal visits, colonoscopy, mammogram. See USPSTF list on our website at denverhealthmedicalplan.orq/uspstf-a No copayment (100% covered). This applies to all preventive services with an A or B recommendat City & DERP Member Handbook 2019 - DHMO - V2 ion from the U.S. Preventive Services Task Force (USPSTF). Annual well visit, well woman exams, well baby care, prenatal visits, colonoscopy, mammograCity & DERP Member Handbook 2019 - DHMO - V2
m. See USPSTF list on our website at denverhealthmedicalplan.ora/uspstf-Not covered.preventive-task-force-listpreventive-task-force-listMaternityPrenaDENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule City & DERP Member Handbook 2019 - DHMO - V2 haring may apply for additional servicesNot covered.Delivery and InpatientŨ 20% coinsurance after Per Occurrence Deductible of $150 and Annual DeductibleŨ 30% coinsurance after Per Occurrence Deductible of $150 and Annual Deductiblehave been methave been metPrescription Drugs* PrescriptionsDeductibl City & DERP Member Handbook 2019 - DHMO - V2 e does not apply.Deductible does not apply.Not covered.DENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. Schedule DENVER HEALTH"JAL PLAN INC.2019 MEMBER HANDBOOKDENVER HEALTH DHMOHEALTH PLANCITY & COUNTY OF DENVER / DERP DENVER EMPLOYEE RETIREMENT PLAN1. ScheduleGọi ngay
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