| Service |
Copayment |
| Outpatient Care |
Primary care visits |
$5 per visit |
Well-child preventive care visits (23 months or younger) |
$5 per visit |
Pediatric visits |
$5 per visit |
Specialty care visits |
$5 per visit |
Same-day outpatient surgery |
$5 per procedure |
Chiropractic visits (30 visits per year) |
$5 per visit |
Allergy testing |
$5 per visit |
Allergy injections |
No Charge |
Respiratory therapy visits |
$5 per visit |
Routine physical exams |
$5 per visit |
Gynecological visits |
$5 per visit |
Scheduled prenatal care and first postpartum visit |
$5 per visit |
Emergency Department visits |
$5 per visit (waived if admitted directly to the hospital) |
Blood, blood products, and their administration 2 |
$5 per visit |
| Hospital Inpatient Care |
Room and board and critical care units |
No charge |
Obstetrical care and delivery, including cesarean section |
No charge |
Physician, surgeon, and surgical services |
No charge |
General and special nursing care |
No charge |
Anesthesia, prescribed drugs, and medical supplies |
No charge |
Blood, blood products, and their administration |
No charge |
Respiratory therapy |
No charge |
|
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| Ambulance Copayment |
Ambulance services and supplies |
No charge |
| Chemical Dependency Services |
Inpatient detoxification |
No charge |
Outpatient individual therapy visits |
$5 per visit |
Outpatient group therapy visits |
$2 per visit |
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five year period) |
$100 per admission |
| Dialysis Care |
Inpatient care |
No charge |
Physician office visits |
$5 per visit |
Dialysis treatment visits |
$5 per visit |
| Durable Medical Equipment |
Durable medical equipment |
No charge |
| Family Planning |
All services related to family planning |
$5 per visit |
| Health Education |
Education for specific conditions:
- Individual visits
- Group visits
|
$5 per visit
No charge |
Education not addressed to a specific condition |
Charges vary |
Health education publications |
No charge |
| Hearing |
Hearing tests |
$5 per visit |
| Home Health Care |
Covered home health care, including physical, occupational, and speech therapy |
No charge |
| Hospice Care |
Covered hospice care |
No charge |
| Imaging, Lab Tests, and Special Procedures |
Imaging, lab tests, special procedures, and ultraviolet light treatment visits |
No charge |
| Infertility Services |
Office visits and outpatient surgery |
$5 per visit |
Outpatient surgery |
$5 per procedure |
Outpatient lab tests, imaging, and special procedures |
No charge |
Hospital inpatient care |
No charge |
Inpatient lab tests, imaging, and special procedures |
No charge |
| Mental Health Services |
Inpatient psychiatric care and hospital alternative services |
No charge |
Outpatient visit |
$5 per visit |
Individual visit |
$5 per visit |
Group visit |
$2 per visit |
| Ostomy and Urological Supplies |
Ostomy and urological supplies |
No charge |
|
|
|
| Out-of-Plan Emergency Care |
Covered services |
Any Copayment that would apply had you received the services from Plan Providers
|
| Physical, Occupational, and Speech Therapy and Multidisciplinary Rehabilitation |
Physical, occupational, and speech therapy:
- Inpatient services
- Outpatient visits
|
No charge
$5 per visit |
Multidisciplinary rehabilitation:
|
No charge
$5 per day |
| Prosthetic and Orthotic Devices |
Covered devices |
No charge |
| Reconstructive Surgery |
Inpatient care |
No charge |
Office visits |
$5 per visit |
Same-day outpatient surgery |
$5 per procedure |
| Skilled Nursing Facility Care |
Care in a Skilled Nursing Facility (up to 100 days per benefit period) |
No charge |
| Transplants |
Inpatient care |
No charge |
Physician office visits |
$5 per visit |
| Vision |
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses |
$5 per visit |
Regular plastic eyeglass lenses every 24 months |
$100 allowance* |
An eyeglass frame every 24 months |
Medically necessary contact lenses |
No charge |
*An allowance is the total expense of an item that is covered. If the cost of the item you select exceeds the allowance, you will pay the difference. |
|
| Annual Copayment Limit |
There are limits to the total amount of Copayments you must pay in a calendar year for certain services covered under this EOC. Those limits are:
- One Member
- Subscriber and all his or her Dependents
|
$1,500
$3,000
|
Copayments for only the following covered services apply toward these limits:
- Ambulance services
- Home health care
- Hospital care
- Imaging, lab tests, and special procedures
- Out-of-Plan emergency care
- Physical, occupational, and speech therapy and multidisciplinary rehabilitation
- Professional services
|
