Benefits and Costs

Some services have $5 co-pay and some have $0 co-pay. For emergency room services, HealthWorx members pay $25 co-pay per visit. Members pay a monthly premium for their coverage. The amount of their monthly premium is determined by their employer.

$5 Co-pay

Services from a licensed medical professional received for reasons related to treatment and diagnosis of a medical condition are covered. Medically necessary home visits are covered.

Not Covered
Services from an out-of-network provider without a prior authorization

Pregnancy and Maternity Services: $0 Co-pay

Prenatal and postnatal care, and hospital services related to labor and delivery are covered.

Dental and Vision Services: IHHS Members Only

Dental and vision benefits are available only to IHHS workers through the SEIU, Local 521 (Service Employees International Union).

For information on covered services, call the SEIU:

$3 Co-pay: $10 for Brand if Generic Option Is Available

Medicines that are prescribed by a licensed medical practitioner are covered. Brand and generic drugs are included. Other types of covered prescriptions include prenatal vitamins, and birth control.

Non-prescription medicines are not covered: Medicines that do not require a doctor’s prescription, such as over-the-counter medicines and dietary supplements are not covered. Experimental medicines are also not covered.

$0 Co-pay

Routine check-ups, screenings tests, and immunizations for adults and newborns, and other office visits with a primary care doctor to prevent problems or identify them early are covered. Some examples of preventive services are:

For more detailed information on preventive services, see page 47 in the HealthWorx Member Handbook/Evidence of Coverage

Inpatient: $0 Co-pay

Services received while hospitalized (inpatient care), including nursing care, and related to surgery are covered. These include a shared room and meals, intensive care unit, medications, anesthesia, lab tests, and other diagnostic, therapeutic, and rehabilitative services.

Not Covered
Costs of a private room, unless medically necessary.

Emergency Services: $25 Co-pay or $0 if Admitted to Hospital

Covers services for an emergency medical condition received at any medical facility. Includes coverage for emergency services received outside of the HPSM service area and by a non-HPSM network facility.

Skilled Nursing Facility: $0 Co-pay

Benefit covers most services including 24-hour nursing care, medicines, medical supplies, and lab procedures received in a skilled nursing home. Daily room and board expenses are also covered. Maximum of 100 days per benefit year.

For complete description of all covered services and exclusions, see page 47 in the HealthWorx Member Handbook & Evidence of Coverage.