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
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