BENEFIT
In-Network Out-of-Network
-0-
Deductible
-$500 Deductible
Physician Services
Office Visits Prenatal
& Postnatal Maternity Care
$20 copayment
70% coinsurance
Specialist
Services
Allergy
Treatments
Routine Gynecological Exam & Pap Test
$35 copayment 70% coinsurance
Well Child Care
Immunizations Newborn
Care
Inpatient Hospital Care
Unlimited Hospital Days (Semi-Private).
$200 copayment
70% coinsurance
Private Room When Medically Necessary
per day (max 3 days)
Rx Card
$10/25/45
Outpatient
Facility Services
X-ray & Laboratory $20 copayment
70% coinsurance
Ambulatory Surgery
$200 copayment
70% coinsurance
Short-Term Therapies
Physical Speech
Occupational
20% coinsurance
70% coinsurance
Respiratory . Cardiac
Rehabilitation
(Short-term therapies are covered from their
original onset up to 60
days.)
Voluntary
Family Planning
Elective Sterilization, Male or Female
$100 copayment
50% coinsurance
Infertility Services for the diagnosis of infertility
50% coinsurance
No coverage
Skilled
Nursing Facility
Facility, supplies, and equipment authorized
8O% coinsurance
70% coinsurance
in lieu of acute care hospitalization within
the service area
Home
Health Care
Authorized in lieu of acute care hospitalization
80% coinsurance
70% coinsurance
within the service area