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Culpeper County Government 2018-2019 Benefit Plan Options
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HealthKeepers 25/1000
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Lumenos HSA 4
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| Deductible
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$1000 (Individual) /$2000 (Family)
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$1500 (Individual) / $3000 (Family)
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| Preventative Care
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| Check-ups, GYN exam and pap test
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100 %
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100 %
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| Prostate Exam and PSA
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100 %
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100 %
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| Mammogrpahy screenings
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100 %
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100 %
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| Screenings/Immunizations
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100 %
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100 %
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| Colorectal cancer screenings
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100 %
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100 %
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| Well Baby Care
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| Check-ups, Visits
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100 %
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100 %
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| Screening tests
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100 %
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100 %
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| Immunizations
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100 %
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100 %
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Annual Vision Exam
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$15.00 co-pay
$30.00 OON allowance
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$15.00 co-pay
$30.00 OON allowance
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Diagnostic Tests
Advanced Diagnostic Imaging
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After Plan Deductible
$25.00 PCP/$50.00 Specialist
After Plan Year Deductible $150.00
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10% after Plan Year Deductible
10% after Plan Year Deductible
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PT/OT/ST
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After Plan Deductible
$25.00 co-pay
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10% after Plan Year Deductible
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Outpatient Surgery
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After Plan Deductible
$150.00 co-pay
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10% after Plan Year Deductible
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Pre/Post Natal Care
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After Plan Deductible
$300.00 co-pay
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10% after Plan Year Deductible
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| Outpatient Mental Health/Substance Abuse Visits
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After Plan Deductible
$300.00 co-pay
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10% after Plan Year Deductible
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| Inpatient Hospital Services
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After Plan Year Deductible
$300.00 day/not to exceed $1500.00 per admission
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10% after Plan Year Deductible
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| Skilled Nursing
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After Plan Year Deductible 20%
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10% after Plan Year Deductible
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Durable Medical Equipment
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After Plan Year Deductible $0
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10% after Plan Year Deductible
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