Physician Services
Doctor's Office Visits (Primary Care)
Well-Child Care
Referral Physician (Includes OB/GYN)
|
$10 copayment per visit
$10 copayment per visit
$10 copayment per visit
$5 additional co-payment at physician's office for Saturday, Sunday, Emergency or holiday visits. |
Emergency Care
Emergency Room
Urgent Care |
$50 copayment per visit (Waived if admitted)
$35 copayment per visit |
Maternity Care
Pre and Post-Natal Visits
Delivery and Hospital Charges
(including routine newborn care) |
$10 copayment per visit
Covered in full |
Hospital Inpatient Care
Physician's/Surgeon's Services
Room and Board
X-ray, Lab and Diagnostic Tests
Physical, Radiation and Inhalation Therapy |
Covered in full
Covered in full
Covered in full
Covered in full |
Hospital Outpatient Care
Physician's/Surgeon's Services
Same-Day Surgery
Laboratory and X-Ray
Casts and Dressings |
Covered in full
Covered in full
Covered in full
Covered in full |
Mental Health Care
Inpatient
Outpatient
|
Payable at 80% of approved charges, maximum of 30 days per calendar year (Up to a maximum of 45 days per calendar year for selected diagnosis)
$25 copayment per visit, maximum of 20 visits per calendar year (Up to a maximum of 52 visits per calendar year for selected diagnosis) |
Alcohol and Substance Abuse
Detoxification
Rehabilitation
Inpatient
Outpatient
|
Covered in full, maximum of 5 days per calendar year
Payable at 80% of approved charges, maximum 30 days per calendar year (Limited to 1 episode of care per lifetime)
$25 copayment per visit, maximum 20 visits per calendar year (Limited to 1 episode of care per lifetime)
|
Other Services
Hospice Care
Extended Care
Home Health Care
Eye Exams (Ophthalmologist or Optometrist)
Dental
Equipment and Appliances
Blood Administration
Skilled Nursing
Family Planning & Infertility
Ambulance (if medically necessary)
Outpatient Physical and Speech Therapy |
Covered in full
Covered in full
Covered in full
$10 copayment per visit. Routine eye exams covered once every 2 years.
Repair to sound, natural teeth damaged by injury or accident, $10 copay
Payable at 80% of pre-approved charges, $800 max. per calendar year
Covered in full
Covered in full, limited to 100 days per calendar year
Payable at 50% coinsurance
$75 copayment - ground, $200 copayment - air
$10 copayment per visit, limited to 60 consecutive visits per calendar year. |
Pharmacy (Prescription Drugs purchased at a participating pharmacy)
Mail Order
|
$10 copayment per Generic prescription
$20 copayment per Preferred Brand prescription
$30 copayment per Non-Preferred Brand prescription
Two times the amount of your prescription copayment, plus an ancillary charge when applicable for up to a 90 day supply |