|
|
Copayments |
|
|
Free Plan |
Low-Cost
Plan
|
At-Cost
Plan |
| Office Visits |
|
Primary Care Physician (PCP)
|
$0 |
$5
|
$15 |
|
Specialist
|
$0 |
$10
|
$25 |
| Preventive Services in PCP’s Office |
|
Immunizations (copayment applies for office visits)
|
$0 |
$5
|
$15 |
|
Routine pediatric and well-child care (no copayment for well-baby visits)
|
$0 |
$5
|
$15 |
| Emergency and Urgent Care Services |
|
Emergency room visits (copayment waived if admitted)
|
$0 |
$25 |
$50 |
|
Urgent care through child’s PCP or BlueCard®
|
$0 |
$5 |
$15 |
| Inpatient Services |
|
Inpatient hospital care (facility and professional); prior authorization
required (90 days per calendar year combined with inpatient mental health)
|
$0 |
$0 |
$0 |
| Outpatient Services |
|
Diagnostic services (lab and X-ray services)
|
$0 |
$0 |
$0 |
|
Rehabilitation benefits: occupational, physical or speech therapy (60 visits
per year per therapy)
|
$0 |
$0 |
$0 |
|
Surgery
|
$0 |
$0 |
$0 |
| Other Services |
|
Bony impacted tooth removal
|
$0 |
$0 |
$0 |
|
Durable medical equipment ($5,000 maximum)
|
$0 |
$0 |
$0 |
|
Home health care (60 days per calendar year, prior authorization required)
|
$0 |
$0 |
$0 |
|
Hospice care services (180-day lifetime maximum, prior authorization required)
|
$0 |
$0 |
$0 |
| Prescription Drugs |
|
Retail and mail order programs available (mandatory generic; 30-day supply per
prescription/refill for retail; 90-day supply per prescription/refill for mail
order)
|
$0 |
Retail
$6 generic
$9 brand-name
Mail Order
$12 generic
$18 brand-name |
Retail
$10 generic
$18 brand-name
Mail Order
$20 generic
$36 brand-name |
| Hearing Services |
|
Audiometric examination (one every calendar year)
|
$0 |
$10 |
$25 |
|
Hearing aid (one per ear in any 2 calendar years)
|
$0 |
$0 |
$0 |
|
Hearing evaluation (one every calendar year)
|
$0 |
$5 PCP; $10 Specialist |
$15 PCP; $25 Specialist |
| Alcohol and/or Drug Abuse Treatment |
|
Detoxification (7 days per admission, 4 admissions per lifetime)
|
$0 |
$0 |
$0 |
|
Non-hospital residential services (90 days per calendar year, 360-day lifetime
maximum)
|
$0 |
$0 |
$0 |
|
Outpatient services (up to 90 visits per calendar year, 360-day lifetime
maximum)
|
$0 |
$0 |
$0 |
| Mental Health |
|
Inpatient services (90 days per calendar year combined with inpatient hospital
services)
|
$0 |
$0 |
$0 |
|
Outpatient services (up to 50 visits per calendar year, can be exchanged for
inpatient hospital days)
|
$0 |
$0 |
$0 |
| Vision
Care
No copayment for vision care |
|
Contact lenses (when medically necessary)
|
|
|
|
|
Eye examinations and refractions (one every 6 months)
|
|
|
|
|
Frames ($55 or under; one every 12 months)
|
|
|
|
|
Lenses (one pair every 6 months)
|
|
|
|
| Dental Care |
|
Diagnostic services
|
|
|
|
|
Bitewing X-rays (one per 12-month benefit period)
|
|
|
|
|
Full mouth X-rays (one per 5-year period)
|
|
|
|
|
Routine exams (one per 6-month period)
|
|
|
|
|
General services
|
|
|
|
|
Anesthesia in conjunction with a covered service
|
|
|
|
|
Endodontic (root canal) therapy – initial endodontic therapy only for permanent
teeth (limited to one per tooth per lifetime)
|
|
|
|
|
Palliative (emergency) treatment of acute conditions requiring immediate care
|
|
|
|
|
Simple extractions (as necessary)
|
|
|
|
|
Surgical extractions (surgical removal of erupted teeth)
|
|
|
|
|
Preventive services
|
|
|
|
|
Routine prophylaxis (one per 6-month period)
|
|
|
|
Sealants: Ages 5 through 9 years on permanent first molars;
Ages 10 through 14 years on permanent second molars
(one sealant per tooth, no repeats)
|
|
|
|
|
Space maintainers (for premature loss of primary posterior molars or permanent
first molars)
|
|
|
|
|
Topical application of fluoride (one per 6-month period)
|
|
|
|
|
Restorative services
|
|
|
|
|
Basic restorative amalgam (silver) and composite (white) fillings for permanent
and deciduous teeth
|
|
|
|
|
Core buildups, including any pins, prefabricated post and core, cast post and
core, in addition to a crown (there is a five-year limitation for replacement;
one buildup or cast post and core is allowed within a five-year period)
|
|
|
|
|
Resin, porcelain and full cast single crowns for permanent teeth (replacement
is limited to one in a five-year period when the crown is not serviceable and
cannot be made serviceable)
|
|
|
|
