Health Flex Plan

Cost & Benefits

Health plan benefits and premium summary. Benefits coverage and premium rates apply to both individual and group members.

The plan is guaranteed issue. You will be enrolled regardless of medical conditions, subject to the cost-sharing provisions during the first 92 days. The plan has limited cost-sharing provisions (co-payments) — refer to the member's agreement for all applicable cost-sharing provisions. Co-payments listed below apply after 92 days of enrollment.

The plan does NOT cover hospitalization or specialist care. American Care medical centers can arrange specialist referrals and hospitalization services; for hospital coverage, members should apply for other state-approved programs.

Preventive health screening

  • Annual physical examination — $0
  • Cervical cancer screen (Pap smear) — $0 annually
  • Non-invasive colorectal cancer screening (three stool guaiacs) — $0 annually
  • Prostate cancer screening (PSA) — $0 annually

Primary care

  • Primary care office visits — $0 per visit
  • Pediatrician visits — $0 per visit

Transportation

  • $0 per visit to the network primary care medical center

Physical Therapy

  • $0 per treatment (office based)

Prescription drug coverage

  • Basic formulary — $4 per prescription
  • Comprehensive formulary — cost plus $4 (requires three days advance order and a 90-day supply order)

Laboratory testing — Hematology

  • PT/INR, PTT — $0
  • Complete Blood Count (WBC, RBC, Platelet, MCV, Hgb/Hct) — $0

Laboratory testing — Chemistry (all $0)

  • Basic & Comprehensive Metabolic Panels, Electrolyte Panel, Lipid Panel, Liver Function Panel
  • ABO Group & RH Type, Albumin, Amylase, ANA w/Reflex titer, Antibody (RBC) w/Reflex ID
  • Bilirubin (Total), C-Reactive Protein, CA 125, Calcium, CO2, CEA, Chloride, Cholesterol (Total)
  • Creatinine w/eGFR, Ferritin, Folic Acid, Glucose, HCG (pregnancy), HDL, Hemoglobin A1C
  • Hepatitis A AB IGM, Hepatitis B Surface AB Qual, Hepatitis C Virus AB, HIV-1/HIV-2 SCR w/Reflexes
  • Iron Total, LDH, Lead (B), Magnesium, Microalbumin (random urine w/creat), Occult Blood in Feces (Guaiac)
  • Phosphorus, Progesterone, Protein Total, PSA Total, Rheumatoid Factor, RPR w/Reflex Titer
  • Rubella IGG AB, SED Rate by MOD West, Testosterone Total, Triglycerides, TSH
  • Urinalysis (dipstick, dipstick w/reflex microscopic, complete), BUN, Uric Acid, Valproic Acid, Vitamin B12/Folic Acid

Laboratory testing — Microbiology

  • Cultures (routine, throat, urine, stool, tissue, genital) — $0
  • Pap smear test — $0
  • (Other laboratory tests are available — check with your provider.)

Office-based minor surgery

  • $0 for: minor surgical procedures, burn local treatment, debridement of nail or skin, ear irrigation, excision of skin lesion, incision & drainage of abscess, skin tag removal, simple splinting, simple laceration repair, cryosurgery, arthrocentesis

Pulmonary testing & treatments

  • Spirometry — $0
  • Aerosol treatments — $0

Radiology — Plain X-rays (2 views)

  • Skull, Face, Cervical, Chest, Abdomen, Pelvis, Extremities — $0

Diagnostic Ultrasound

  • Aorta, Kidneys, Pancreas — $0
  • Breasts, Gallbladder & Liver, Pelvis, Scrotum & testicles, Soft tissue, Thyroid — $0
  • Other ultrasound — $0

Cardiovascular testing

  • Electrocardiogram — $0
  • 24-hour Holter Monitor — $0
  • Echocardiogram with Doppler — $0
  • Carotid Arterial Imaging / Doppler — $0
  • Extremities Vascular Imaging — $0

Vaccines & office-based injections

  • DT vaccine (tetanus, diphtheria) — $0
  • Hepatitis B vaccine — $45
  • Influenza vaccine — $15
  • PPD/tine (TB screen) — $0
  • TD (tetanus vaccine) — $0
  • Toradol (analgesic) — $0
  • Solumedrol (corticosteroid) — $0
  • Rocephin (antibiotic) — $30

Vision & hearing

  • Vision screening — $0
  • Hearing screening — $0

Specialist Care

Not a covered benefit, but can be arranged through American Care medical centers' provider network. See the provider directory.

Hospitalization

Hospital service is not a covered benefit of the American Care Health Flex Plan. American Care medical centers will arrange for required hospitalization services. For coverage of this type of service, beneficiaries should apply for other state-approved programs.

Download the Basic Medication Formulary (PDF)

The formulary PDF is dated 2008. Contact the plan to confirm current medication coverage.