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Citrus Individual - Summary Of Plan Benefits Quick Menu Small FontLarge FontPrint
 
 
Benefit Covered Service Citrus 215 Citrus 220 Citrus 225 Citrus 230
Contract Year Deductible3 Does not apply to maximum out-of-pocket $0 $100 per individual
$200 per family		 $1000 per individual
$2000 per family		 $2000 per individual
$4000 per family

Medical Services

All medical care must be provided or authorized by individual's Primary Care Physician1

Deductible will apply first to all services except those rendered in the Primary Care Physician's office.

Primary care services2

$15 co-pay

$20 co-pay

$25 co-pay

$30 co-pay
Specialist services $25 co-pay $30 co-pay $35 co-pay $40 co-pay
Annual physicals $15 co-pay $20 co-pay 20% coinsurance $25 co-pay
Immunizations $0 co-pay $0 co-pay $0 co-pay $0 co-pay
CT, PET, MRI2 $25 per test $30 per test $35 per test $40 per test
Mammogram $0 co-pay $0 co-pay $0 co-pay $0 co-pay
Diagnostic lab $10 co-pay $10 co-pay 20% coinsurance 50% coinsurance

Inpatient Hospital Services

Medically necessary, and directed by the Primary Care Physician

   $500 per admission $750 per admission 20% coinsurance 40% coinsurance

Emergency Care

Emergency services in/out of service area

   $100 per encounter
(waived if admitted)		 $150 per encounter
(waived if admitted)		 20% coinsurance 50% coinsurance

Urgent Care

 In network facility $35 co-pay $35 co-pay 20% coinsurance 40% coinsurance
Out of network facility $75 co-pay $75 co-pay 40% coinsurance 60% coinsurance

Hospital Outpatient

Ambulatory Surgical Center

   $250 per surgery $400 per surgery 20% coinsurance 50% coinsurance

Behavioral Health Services

Mental Health Services

Outpatient
20 visits per contract year

 $25 co-pay $30 co-pay 20% coinsurance $40 co-pay

Inpatient
30 days per contract year

 $500 per admission $750 per admission 20% coinsurance 40% coinsurance
Substance Abuse Outpatient
44 visits per contract year		 $25 co-pay $30 co-pay 20% coinsurance $40 co-pay
Inpatient
5 days per contract year		 $500 per admission $750 per admission 20% coinsurance 40% coinsurance

Specialty Services

Annual maximums may apply for specialty services. See your Certificate of Coverage for additional information.

 Chiropractic $25 co-pay $30 co-pay $35 co-pay $40 co-pay
Podiatry $25 co-pay $30 co-pay $35 co-pay $40 co-pay
Skilled nursing facility(max 45 days) $100 per admission $150 per admission $35 co-pay $40 co-pay
Home health care (30/year) $25 co-pay $30 co-pay 20% coinsurance 50% coinsurance
Dermatology $25 co-pay $30 co-pay $35 co-pay $40 co-pay
Ambulance $100 per incident $150 per incident 20% coinsurance 50% coinsurance
Durable medical equipment $25 per item $35 per item 20% coinsurance 50% coinsurance

Maximum Out-of-Pocket

Co-payments and coinsurance apply to maximum out-of-pocket

 Individual $1500 per Individual $2500 per Individual $5000 per Individual $7500 per Individual
Family $3000 per Family $5000 per Family $10000 per Family $15000 per Family
Lifetime Maximum Benefit $2,000,000
1Except for open access specialties as required by Florida Statute
2When service is performed at specialist's office or free-standing diagnostic facility.
3Co-payments do not apply to deductible.
 
 
Features
  • Comprehensive HMO Coverage
  • Minimal Paperwork
  • 12 Month Rate guarantee
  • Flexible benefit plans
  • Preventative care
  • Inpatient and outpatient services
  • Prescription drug coverage available
  • Maternity coverage available
  • Outstanding physician network
  • 24-hour Citrus Nurse Line
Pharmacy Option
  RX1 RX2 RX3
  No deductible $250 deductible Generic Only
No deductible
Generic $10 co-pay $10 co-pay $10 co-pay
Preferred Brand $30 co-pay $30 co-pay NA
Non-Preferred Brand $50 co-pay $50 co-pay NA
Maternity Option

A Maternity Endorsement is available. To be eligible for coverage, the endorsement must have been in effect continuously for a period of 90 days immediately preceding the date of conception. Coverage will begin after the first 90 day waiting period has taken place according to policy guidlines and benefits will be paid out once delivery has been completed.There will be no facility co-payment if a birthing center is used. If an acute care hospital is used, the normal co payments, deductibles and coinsurance provisions will apply.

To be covered, services must be medically necessary, and may be subject to pre-existing condition limitations.

Please see your policy for more information on medical necessity and other specific plan benefits.

Exclusions

A partial listing of the services that are excluded are as follows:

  • All services not specifically listed in the Contract or in any rider or endorsement, unless such services are specifically required by state law.
  • Any service which is not medically necessary
  • Elective cosmetic surgery
  • Hearing aids or eyeglasses
  • Dental care, or oral appliances
  • Elective abortions
  • Infertility services
  • Work-related injuries or conditions
  • Complementary and Alternative Healing Methods (CAM)
Member Financial Obligations

As a member of Citrus Health Care, you are responsible for certain financial obligations. The subscriber is responsible for his/her financial obligations as well as those for each Dependent listed on the Individual Enrollment Application.

 Our Lines of Business
Citrus Individual
Citrus Medicaid
Citrus Medicare
Tango Plan
Mail Order Pharmacy

PhoneContact Contact
Citrus Health Care All Plans
Citrus Health Care
5420 Bay Center Drive, suite 250 Tampa, FL 33609 www.citrushc.com
Phone : 813-490-8900
Fax : 813-490-8909
Toll Free Phone per Plan
Medicare: 1-866-769-1157
Medicare(TTY/TDD): 711
Medicaid: 1-877-255-3081
Tango: 1-866-769-1158 (Hours 8:30am to 5pm EST From Monday to Friday)
Medical Management: 1-866-769-1159
Provider Service: 1-866-769-1160
Customer Service: 1-877-624-8787
To report suspected fraud and/or abuse, Please call 1-800-830-0817 or Email lketterman@phyhc.com