| |
|
|
| Medical
Care |
In-Network |
Out-of-Network |
| Office
Visit Copay |
$15 |
Deductible
& Coinsurance |
| Hospital
Visit Copay |
$250
per admission |
Deductible
& Coinsurance |
| Urgent
Care Copay |
$50 |
Not
Covered |
Emergency
Room Copay
(waived if admitted) |
$75 |
$75 |
| Outpatient
Surgery Copay |
$100 |
Deductible
& Coinsurance |
Annual
Deductible
(Individual/2 person/3+ person) |
Not
applicable |
$400/$800/$1200 |
| Coinsurance |
Not
applicable |
30%
to a
maximum of
$2000/$4000/$6000 |
| Lifetime
Maximum |
Unlimited |
$1,000,000 |
| |
|
|
| Preventative
Care |
|
|
| Well
child care* |
$15 |
Deductible
& Coinsurance |
| Periodic,
routine health exams* |
$15 |
| Routine
eye exams - 1 exam every 24 months |
$15 |
| Routine
OB/GYN visits - 1 annual exam |
$15 |
| Mammography
- 1 baseline 35-39, annual screening age 40+, and as medically
necessary |
No
charge |
| Hearing
screening - once every 2 years |
$15 |
| |
|
|
| Medical
Care |
|
|
| Primary
care office visits |
$15 |
Deductible
& Coinsurance |
| Specialist
consultations |
$15 |
| OB/GYN
care - no referral needed |
$15 |
Maternity
care
(initial visit only, no charge after) |
$15 |
| Laboratory |
No
charge |
| X-ray
and Diagnostic Testing |
No
charge |
| Allergy
Services (office visits/testing) |
$15 |
| Allergy
Services (injections, 80 visits in 3 yrs) |
No
charge |
| |
|
|
| Hospital
Care - Prior Authorization Required |
|
|
| Semi-private
room |
$250
per admission |
Deductible
& Coinsurance |
| Maternity
and newborn care |
$250
per admission |
Skilled
nursing facility -
up to 120 days per calendar year |
$250
per admission |
Rehabilitative
services -
up to 60 days per person per calendar year |
No
charge |
Outpatient
surgery -
in a hospital or surgu-center |
$100 |
| |
|
|
| Emergency
Care |
|
|
| Walk-in
centers |
$15 |
Deductible
& Coinsurance |
| Urgent
care (at participating centers only) |
$50 |
Not
covered |
| Emergency
care (waived if admitted) |
$75 |
$75 |
Ambulance
(air & land subject to maximum per trip) |
No
charge |
No
charge |
| |
|
|
| Other
Health Care |
|
|
| Outpatient
rehabilitative services |
$15 |
Deductible
& Coinsurance
|
| Prosthetic
devices |
20% |
| Durable
medical equipment |
20% |
| |
|
|
| Mental
Health/Substance Abuse Care |
|
|
| Inpatient |
$250
per admission |
Deductible
& Coinsurance |
| Outpatient/Office
visits |
$15 |
| |
|
|
| *
Schedule of health examinations |
6
exams birth to 1 yr
|
| |
6
exams 1 through 5 yrs
1 exam every 2 yrs from 6 to 10
1 exam annually from 11 to 21
1 exam every 5 yrs from 22 to 29
1 exam every 3 yrs from 30 to 39
1 exam every 2 yrs from 40 to 49
1 exam annually from 50 yrs + |
