Polk HealthCare Plan Members
Welcome Polk HealthCare Plan (PHP) members.
Our team is available to help you understand your plan benefits and use the plan to meet your needs. If you’re looking for information about free healthcare, a free clinic, a low cost clinic, diabetes education or indigent healthcare resources, we can help. Below you will find information about the benefits, coverage and services available to you. You must notify customer service if you have any major changes in your life, including a new address, a change in family size, income or a change in job.
Your Polk HealthCare Plan Membership Card and Pharmacy Identification Card
Every plan member will receive their own Polk HealthCare Plan membership card and pharmacy identification card once enrolled. You will need to present your membership card and pharmacy identification card any place you receive care or fill a prescription.
When you receive your cards, please check to make sure the information on them is correct. If there is an error on either card, please call the customer service number on the card. The cards can only be used by the person listed on the card. Do not let anyone else use your card. If you do, you will have to pay for their costs and will lose your eligibility for the Polk HealthCare Plan.
Coverage
Coverage begins on the first or 15th day of the month based on date of enrollment. Coverage ends the last day of the month you are eligible for services.
Out-of-County Care
Care received outside of Polk County and PHP Provider Network is not covered by the plan.
Canceling or Rescheduling Appointments
You are required to notify the provider you are seeing at least 24 hours in advance if you must cancel or reschedule an appointment.
Your provider may have a policy of charging for an appointment you do not keep without notifying them in advance. The healthcare plan will not pay the copay if you miss your appointment and the provider charges you. You will be responsible for any charges for the missed appointment.
If you miss three appointments within a 12-month period without notifying your PCP, you will lose your PHP coverage.
Getting Care through the Polk HealthCare Plan
PHP partners with local providers, clinics and hospitals in Polk County to form a network of care for its members. If you receive services from any providers, lab or pharmacy outside of the PHP network, or receive services without the required advance authorizations, e.g., Primary Care Provider changes or Specialty Care referrals, the plan will not pay the claims and you will be responsible for all costs.
Copays
Your plan type is identified on your enrollment card. Before making a doctor’s appointment, unless it is with your PCP, you must be sure your plan covers the type of care you are seeking. If you are not sure if the service is covered, contact a customer services representative at (863) 533-1111.
| Essential Care Choice Service and Description | In-Network Provider | Plan Year Benefit Limit(s) |
|---|---|---|
| Preventive/Annual Screenings | $0 copay | 1 visit/test per plan year for: Pap smear, colonoscopy, prostate exam, routine annual exam |
| Primary Care Physician regular office visit/sick visit | $1 copay | Primary Care Physicians (PCP) are family providers, internal medicine providers and general practitioners. Note: Services rendered by PCP not assigned to the member will not be covered |
| Urgent Medical Care | $1 copay | No limit |
| Emergency Room | $25 copay | $1,500 annual cap per member; emergent condition required to demonstrate medical necessity |
| Hospital Care - Inpatient | $0 copay | 6 days per admission and up to 30 days per plan year |
| Hospital Care - Outpatient | $0 copay | Limited to 24 hours |
| Physical Therapy - Outpatient | $5 copay | 36 visits |
| Speech Therapy - Outpatient | $5 copay | 36 visits |
| Occupational Therapy - Outpatient | $5 copay | 36 visits |
| Pain Management | $10 copay | |
| Behavioral Health | $1 copay | Limits for visits based on services provided. Please contact (863) 533-1111 for specifics |
| Specialty Care | $5 copay | Requires referral and limited to 15 visits combined |
| Bone Density (Nuclear Medicine) | $5 copay | 2 tests |
| Blood work | $0 copay | Must be at Labcorp/no limit |
| X-Rays | $3 copay | No limit |
| CT Scans | $5 copay | 4 scans |
| MRI/MRA | $10 copay | 3 MRIs/MRAs |
| Pet Scan | $20 copay | 2 tests |
| Ultrasound | $5 copay | 6 ultrasounds |
| Chronic Care Choice Service and Description | In-Network Provider | Plan Year Benefit Limit(s) |
|---|---|---|
| Preventive/Annual Screenings | $0 copay | 1 visit/test per plan year for: Pap smear, colonoscopy, prostate exam, routine annual exam |
| Primary Care Physician regular office visit/sick visit | $1 copay | Primary Care Physicians (PCP) are family providers, internal medicine providers and general practitioners. Note: Services rendered by PCP not assigned to the member will not be covered |
| Urgent Medical Care | $1 copay | No limit |
| Emergency Room | $25 copay | $1,500 annual cap per member; emergent condition required to demonstrate medical necessity |
| Hospital Care - Inpatient | $0 copay | 6 days per admission and up to 30 days per plan year |
| Hospital Care - Outpatient | $0 copay | Limited to 24 hours |
| Physical Therapy - Outpatient | $3 copay | 36 visits |
| Speech Therapy - Outpatient | $3 copay | 36 visits |
| Occupational Therapy - Outpatient | $3 copay | 36 visits |
| Pain Management | $10 copay | |
| Behavioral Health | $1 copay | Limits for visits based on services provided. Please contact (863) 533-1111 for specifics |
| Specialty Care | $3/$5 copay | Requires referral and limited to 20 visits combined. Contact (863) 533-1111 for specifics |
| Bone Density (Nuclear Medicine) | $5 copay | 2 tests |
| Blood work | $0 copay | Must be at Labcorp/no limit |
| X-Rays | $3 copay | No limit |
| CT Scans | $5 copay | 4 scans |
| MRI/MRA | $10 copay | 3 MRIs/MRAs |
| Pet Scan | $20 copay | 2 tests |
| Ultrasound | $5 copay | 6 ultrasounds |
Prescriptions
Filling Your Prescriptions
You must have your prescriptions filled at a participating pharmacy provider to get medications filled at the copay price listed. You can use most drugstores and retail pharmacies in Polk County and a few outside of Polk in Poinciana, Avon Park and Wauchula, but it is your responsibility to verify with the pharmacy before filling prescriptions. You can call the customer service number listed on the back of your Pharmacy Identification card to help you identify a participating pharmacy in your area.
Extra Medication for Planned Out-Of-County Travel
To assist with your medication regimen while you are away from home, an additional 15-day supply of your medication can be issued once per year.
Emergency Refill When Out-Of-County
If you are not in Polk County and need medication, a 10-day emergency supply can be filled by a retail pharmacy. This emergency option is intended to allow you time to get back in the county to get your medication filled at participating pharmacy and should only be utilized in cases of unplanned, emergency situations.
| Essential Care Choice Plan Prescription Drugs | Non-Participating Pharmacy | Participating Pharmacy Provider | |
|---|---|---|---|
| Generic Medications | No Coverage | $1 copay | Formulary Drugs only (Medication List) |
| Brand Name Medication | No Coverage | $5 copay | Formulary Drugs only (Medication List) |
| Chronic Care Choice Plan Prescription Drugs | Non-Participating Pharmacy | Participating Pharmacy Provider | |
|---|---|---|---|
| Generic Medications | No Coverage | $0 copay | Formulary Drugs only (Medication List) |
| Brand Name Medication | No Coverage | $3 copay | Formulary Drugs only (Medication List) |