Family Primary Care Practice COPAYMENT Office Visit General applies towards Practice meeting the COPAYMENT Internal annual OOPL, but applies towards Medicine not the meeting the DEDUCTIBLE annual OOPL Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy Benefit: WPE eligible WPE eligible WPE eligible High Participating PARTICIPANTS PARTICIPANTS PARTICIPANTS DEDUCTIBLE Wisconsin Public in (Program in PO 6 who are in PO 4 including Health Plan WPE Option PO 2 and not eligible for MEDICARE eligible (PO 7) Employer’s (WPE) MEDICARE nor enrolled in eligible and PARTICIPANTS 3 eligible and MEDICARE as enrolled enrolled in PO 6 the primary and PO 7) payor3 Specialist No medical $25 per visit, No medical After COPAYMENT COPAYMENTs DEDUCTIBLE COPAYMENTs DEDUCTIBLE: Applies to: need not be met $25 per visit Specialists first URGENT CARE COPAYMENT COPAYMENTS applies towards count towards meeting the meeting the annual OOPL OOPL, but not the DEDUCTIBLE ILLNESS/INJURY 100% After 100% After related services DEDUCTIBLE: DEDUCTIBLE: beyond the office 90% 90% visit COPAYMENT (10% member (10% member (if applicable) cost to OOPL) cost to OOPL) EMERGENCY $60 $75 COPAYMENT $60 After Room Copay to OOPL. After DEDUCTIBLE, (Waived if COPAYMENT, $75 to OOPL. admitted as an DEDUCTIBLE and After inpatient directly DEDUCTIBLE and from the (10% member copay 90% (10% EMERGENCY cost to OOPL) member cost to room or for OOPL)
Family Practice General Practice Internal Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy COPAYMENT applies towards meeting the annual OOPL, but not the DEDUCTIBLE Primary Care Office Visit COPAYMENT applies towards meeting the annual OOPL Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Specialist COPAYMENT Applies to: Specialists URGENT CARE No medical COPAYMENTs $25 per visit, DEDUCTIBLE need not be met first COPAYMENTS count towards meeting the OOPL, but not the DEDUCTIBLE No medical COPAYMENTs After DEDUCTIBLE: $25 per visit COPAYMENT applies towards meeting the annual OOPL ILLNESS/INJURY related services beyond the office visit COPAYMENT (if applicable) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) EMERGENCY Room Copay (Waived if admitted as an inpatient directly from the EMERGENCY room or for $60 $75 COPAYMENT to OOPL. After COPAYMENT, DEDUCTIBLE and (10% member cost to OOPL) $60 After DEDUCTIBLE, $75 to OOPL. After DEDUCTIBLE and copay 90% (10% member cost to OOPL)
Exhibit1_PBP_Agreement_Rev.docx