Medical Services: PLANS 10 & 10E* PLANS 5 & 15E* PLANS 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 Inpatient Detoxification - 7 days $20 Co-payment $25 Co-payment $30 Co-payment * No Hospital Co-Payment for Plans 10E, 15E or 20E ^ Top of Page ^