Preventive Care
|
Routine mammogram and Pap smears, PSA screening, colonoscopy and sigmoidoscopy
|
$0
|
---|
|
Routine child care and immunizations (through age 18)
|
$0
|
---|
|
Routine adult physical exam (19 years and above, one per plan year)
|
$0
|
---|
Physician Services
|
Routine outpatient laboratory tests and X-rays
|
4% after deductible
|
---|
|
Office visits (excludes certain diagnostic lab tests and X-ray)
|
4% after deductible
|
---|
|
Lab tests and X-rays
|
4% after deductible
|
---|
|
Allergy injections
|
4% after deductible
|
---|
|
Inpatient services
|
4% after deductible
|
---|
|
Outpatient surgery and diagnostic tests
|
4% after deductible
|
---|
Hospital Services
|
Inpatient care (semi-private room and board, nursing care, ICU)
|
4% after deductible
|
---|
|
Physician visits to emergency room
|
4% after deductible
|
---|
|
Outpatient surgery
|
4% after deductible
|
---|
|
Outpatient tests, lab and X-ray
|
4% after deductible
|
---|
|
Ancillary services
|
4% after deductible
|
---|
|
Organ transplants
|
4% after deductible
|
---|
Other Medical Services
|
Emergency room
|
$100 co-pay (waived if admitted within 24 hours for same condition)
|
---|
|
Urgent care
|
$65 co-pay (waived if admitted within 24 hours for same condition)
|
---|
|
Home health care and hospice services
|
$0
|
---|
|
Skilled nursing facility (up to 100 days per plan year)
|
4% after deductible
|
---|
|
Ambulance services
|
4% after deductible
|
---|
|
Durable medical equipment
|
4% after deductible
|
---|
|
Physical, speech, hydrotherapy, occupational and acupuncture therapy (limited to 45 visits per plan year, combined)
|
4% after deductible
|
---|
Mental Health and Substance Abuse
|
Inpatient mental health or substance abuse
|
4% after deductible
|
---|
Outpatient mental health or substance abuse
|
|
4% after deductible
|
---|