| Feature / Service |
Network Service You Pay |
Non-Network ServiceYou Pay |
Physician Services
Office visits for routine care; diagnosis and treatment of an illness or injury.
|
$25 per PCP office visit
$50 per specialist office visit |
30% after deductible
(Plan pays 70%) |
Preventive Care
Periodic checkups, annual physicals, well-child care, immunizations, mammography and well-woman care. |
$25 per office visit
No copay for mammogram |
Not covered |
Inpatient Hospital Services
Semi-private room and board charges, intensive care, cardiac care, etc. |
Plan pays 100% |
30% after deductible (Plan pays 70%) |
Emergency Room Care
Services administered for conditions meeting the definition of an emergency. |
$200 per emergency visit for all medically necessary treatment. If you are admitted, copayment is waived and you must call your PCP within 2 working days of admission. |
Urgent CareCenter
Services administered for conditions requiring immediate care when your PCP is not available, or after normal office hours. |
$100 per visit |
30% after deductible (Plan pays 70%) |
Surgery
Anesthesia and use of an operating room or related facility in a hospital or authorized outpatient center. |
Plan pays 100% |
30% after deductible (Plan pays 70%) |
Lab and X-Ray Services
X-rays or laboratory tests for diagnosis or treatment. |
Nothing
(Plan pays 100%) |
30% after deductible (Plan pays 70%) |
Outpatient Physical Rehabilitation
Short-term physical, occupational or speech therapies. |
$50 per office visit
Limit of 20 visits per calendar year
|
30% after deductible
(Plan pays 70%)
(combined network/non-network) |
Home Health Care
Services provided in the home by an RN, LPN or contracted therapist. |
No Copayment
40 days per calendar year limit |
30% after deductible
(Plan pays 70%)
(combined network/non-network) |
Skilled Nursing Facility/ Inpatient Physical Rehabilitation
Confinement for skilled nursing services in a hospital of specialized facility. |
Plan pays 100%
120 days per calendar year limit |
30% after deductible
(Plan pays 70%)
(combined network/non-network) |
Hospice Care
Room and board in a licensed facility or services of medical personnel in your home.**. |
No copayment
Plan pays 100% |
30% after deductible
(Plan pays 70%) |
Durable Medical Equipment
Splints, braces, non-surgically implanted prostheses, specified medical equipment for use in the home. |
No copayment
100% covered |
30% after deductible
(Plan pays 70%)
Authorization required if over $300 |
Managed Mental Health and Substance Abuse
Outpatient short-term evaluation; crisis intervention; alcohol or drug detoxification; medical complication of chemical dependency. |
25% (Plan pays 75% for first 40 visits)
40% (Plan pays 60% for each visit after the 40th)
Substance Abuse –
30 visits total |
50% after deductible |
Managed Mental Health and Substance Abuse
Inpatient treatment in a hospital or residential treatment center. |
90% after deductible
Limit of 45 days per calendar year |
50% after deductible |
