Covers all mandated Preventive Benefits required by PPACA Note: This list will be updated from time to time and a current list of covered preventive services is available by visiting Healthcare.gov/center/regulations/prevention.html
Medical benefits – Must utilize PHCS participating provider or facility
21 Preventive Services for Adults
100% Coverage for mandated 21 preventive services
28 Preventive Services for Women
100% Coverage for mandated 28 preventive services
31 Preventive Services for Children
100% Coverage for mandated preventive 31 preventative services
Telemedicine: Teledoc
$0 Copay, Unlimited use per covered family member
Primary Care Office Visit
$20 Copay, (Max 3 visits per calendar year)
Specialists Office Visit
$50 Copay, (Max 3 visits per calendar year)
Urgent Care
$50 Copay, (Max 3 visits per calendar year)
Diagnostic X-Ray, Lab
$50 Copay by date of service, (Max 5 visits per calendar year)
*CT Scan or MRI
$200 Copay, (Max 1 CT scan or MRI per calendar year)
* 3 D MRI’s or Contrast Services for MRI’s and ST Scans are not covered, pre-authorization required prior to scans.
Prescription Drug Benefits – Citizens RxClick HERE for Drug Coverage Tier Information
Tier 1 – Low Cost Generics
$1 Copay
Tier 2 – Generics
10% Coinsurance
Tier 3 – Preferred Brands
20% Coinsurance
Tier 4 – Non-Preferred Brands
40% Coinsurance
Tier 5 – Generic and Preferred Specialty
10% Coinsurance (Plan pays 90% up to a maximum of $150 per Rx
Tier 6 – Non-Preferred Specialty
20% Coinsurance (Plan pays 80% up to a maximum of $250 per Rx