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Covered Benefits and Sercies - Staywell Kids
| Benefits | Co-payment |
| Well-Child Care and School Physicals | $0 |
| Office Visits for Minor Illnesses, Accident Care (PCP) | $5* |
| Specialist Office Visit(if referred by PCP) | $5 |
| Hospital Inpatient Medical and Surgical Care | $0 |
| Unauthorized Use of Emergency Services (Co-payment is waived if visit is appropriate use of ER, PCP has authorized or patient is admitted to the hospital) | $10 |
| Emergency transportation | $10 |
| Surgeon’s Fees | $0 |
| Prenatal Care and Delivery (Up to 3 days or until discharge.) | $0 |
| Pharmacy Coverage (Includes all drugs available under the Florida Medicaid program) | $5 |
| Generic Prescriptions (31-day supply) | $5 |
| Brand Name Prescriptions (Available only if no generic is available or if brand name is considered medically necessary) | $5 |
| Behavioral Health Services Outpatient Services (Benefit limitations shall not be any less favorable than those for physical illinesses generally) | $5 |
| Inpatient Services (Benefit limitations shall not be any less favorable than those for physical illinesses generally) | $0 |
| Substance Abuse Rehabilitation and Treatment Outpatient Services (Benefit limitations shall not be any less favorable than those for physical illinesses generally) | $5 per session |
| Inpatient Services (Benefit limitations shall not be any less favorable than those for physical illinesses generally) | $0 |
| Diagnostic Testing (Laboratory, X-rays) | $0 |
| Anesthesia Services | $0 |
| Outpatient Physical, Occupational, Respiratory and Speech Therapies (Up to 24 sessions within a 60-day period per episode or injury, with the 60 day period beginning with the 1st treatment.) | $5 per session |
| Home Health Services (Skilled nursing only; includes Hospice services) | $5 |
| Skilled Nursing Facility (Pre-authorized, 100 days per year) | $0 |
| Durable Medical Equipment and Prosthetic Devices (Pre-authorized, medically necessary equipment) | $0 |
| Routine Vision and Hearing Screening (PCP) | $0 |
| Refractions/Corrective Lenses (1 pair every 2 years or when head size or prescription changes warrant) | $10 |
| Chiropractic Services (24 visits per calendar year) | $5 |
| Organ Transplants (Includes pre-transplant, transplant and post-transplant services when authorized by insurer at approved facility) | $0 |
OTC Program($10 per family per month) | $0 |
Last modified: 01/05/2010
