| Benefits and Services |
Sample Copayments |
Deductible
Maximum of 3 separate deductibles per family |
None |
Coinsurance maximum
Maximum of 3 separate coinsurance maximums per family |
None |
| Primary Care Physician office visits |
$10 |
| Specialist physician office visits |
$25 |
| Preventive Services in PCP’s Office |
| Routine pediatric/adult & well child care |
$10 |
| Immunizations |
$10 |
| Women’s Health Care |
|
Routine gynecological exam |
$25 |
| Mammography screenings/diagnostics |
No charge |
| Maternity care, including delivery |
$25 initial visit;
100% subsequent visits |
| Emergency and Urgent Care Services |
| Urgent care through your PCP |
$10 |
| Emergency room visit (copay waived if admitted to hospital) |
$50 |
| Inpatient Services |
| Inpatient hospital services (facility and professional) |
$100 per day for first 5 days for each admission |
| Skilled nursing care (60 days per benefit period) |
$100 per day for first 5 days for each admission |
| Outpatient Services |
| Surgery |
No charge |
| Diagnostic testing
|
|
MRI, MRA, CT scans, pet scans, nuclear cardiology
|
$75 per test |
Other diagnostic testing (lab tests, X-rays)
|
No charge |
| Physical, speech or occupational therapy (45 combined visits/benefit period) |
$25/visit |
| Chemotherapy, dialysis or radiation |
No charge |
| Other Services |
| Durable medical equipment ($5,000 benefit period maximum) |
No charge |
| Home health/home infusion services |
$10/visit |
| Hospice care (180 days lifetime maximum) |
No charge |
Prescription drugs, including oral contraceptives
(30-day supply per prescription/refill) |
|
Tier 1
Tier 2
Tier 3
|
$10
$20
$35 |
| Mail order program (up to a 90-day supply) |
|
Tier 1
Tier 2
Tier 3
|
$20
$40
$105 |
| Mental Health |
| Inpatient services (30 days/benefit period. 30 inpatient days can be converted
to outpatient professional visits or partial hospitalization days. Every two
days used shall reduce by one day the number of inpatient days remaining.) |
$100 per day for first 5 days for each admission |
| Outpatient services (60 visits/benefit period) |
$25 |
| Substance Abuse |
| Detoxification (7 days per admission/4 admissions per lifetime) |
$100 per day for first 5 days for each admission |
Non-hospital residential services
(30 days/benefit period; 90 days/lifetime) |
No charge for initial visit
50% subsequent visits
|
| Outpatient services (30 visits/benefit period; 120 visits per lifetime) |
No charge |
| Partial hospitalization (An additional 30 visits of outpatient or partial
hospitalization may be exchanged 2:1 for inpatient non-hospital residential
treatment days, subject to the 120 outpatient lifetime maximum.) |
No charge |
