| Medical Services |
10 & 10E* |
5 & 15E* |
20 & 20E* |
Office Visits / Specialist Visits, Preventive Care, Physical Exams, Well
Baby / Child Care, Immunizations, Eye Exams, Hearing Exams, X-rays / Lab
tests, Annual gynecological exams, Mammography exams for women ages 35
& over and as perceived necessary by PCP prior to age 35, Maternity
office visits, Pre-Admission Medical Testing Services. |
$10 Co-Payment (waived for well child exams from birth to age 19) |
$15 Co-Payment (waived for well child exams from birth to age 19) |
$20 Co-Payment (waived for well child exams from birth to age 19) |
Specialty Care Services (upon referral by PCP) including chiropractic and podiatry care, Surgeons and Anesthesiologists. |
$10 Co-Payment |
$15 Co-Payment |
$20 Co-Payment |
|
Second Opinions at your request |
$10 Co-Payment |
$15 Co-Payment |
$20 Co-Payment |
Second Opinions at our request |
No Co-Payment |
No Co-Payment |
No Co-Payment |
|
Physical Therapy, Speech Therapy and Occupational Therapy - 20 outpatient visits, 30 inpatient days per diagnosis per year. |
No Co-Payment |
No Co-Payment |
No Co-Payment |
|
| Hospital Services: |
Surgeon & Physician Fees, Semi Private Room (private if medically necessary), Operating and Recovery Room Fees, Intensive and Special Care Units, X-rays / Lab tests, Anesthesia, Prescribed Drugs, Nursing Services |
$250* Co-payment |
$250* Co-payment |
$250* Co-payment |
| |
|
*No Hospital Co-Payment for Plans 10E, 15E or 20E |
|
Maternity Care |
$10 Co-payment for pre-natal visits |
$15 Co-payment for pre-natal visits |
$20 Co-payment for pre-natal visits |
Delivery & care of Mother and Baby Physician's Hospital Visits - Well Baby Nursery Care |
$250* Co-payment for inpatient delivery |
$250* Co-payment for inpatient delivery |
$250* Co-payment for inpatient delivery |
| |
|
*No Hospital Co-Payment for Plans 10E, 15E or 20E |
|
Emergency Care |
$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable |
$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable |
$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable |
Ambulance (limited to Emergency conditions unless approved in advance by the Plan) |
No Co-payment |
No Co-payment |
No Co-payment |
| |
|
*No Hospital Co-Payment for Plans 10E, 15E or 20E |
|
Skilled Nursing Care Facility - limit of 45 days per calendar year |
No Co-payment |
No Co-payment |
No Co-payment |
|
Home Health Care - limit of 60 visits per calendar year |
No Co-payment |
No Co-payment |
No Co-payment |
|
Hospice Services - limit of 210 days per calendar year, including 5 bereavement visits |
No Co-payment |
No Co-payment |
No Co-payment |
|
Durable Medical Equipment |
No Co-payment |
No Co-payment |
No Co-payment |
|
| Mental Health Services: |
Outpatient - up to 20 visits per calendar year for short term evaluation and therapy |
$20 Co-payment |
$25 Co-payment |
$30 Co-payment |
Inpatient - up to 30 days of acute inpatient psychiatric care per calendar year as well as 20 inpatient hospital visits |
$250* Co-payment |
$250* Co-payment |
$250* Co-payment |
| |
|
*No Hospital Co-Payment for Plans 10E, 15E or 20E |
|
| Substance Abuse Services: |
Outpatient - 60 visits per calendar year for diagnostic and treatment services, of which 20 visits may be used for Family Therapy |
$20 Co-payment |
$25 Co-payment |
$30 Co-payment |
Inpatient Detoxification - 7 days |
|
|
|
| |
|
*No Hospital Co-Payment for Plans 10E, 15E or 20E |
