Statewide PPO


	BENEFIT STATEWIDE PPO In-Network Out-of-Network Physician Services Office Visits • Prenatal & Postnatal Maternity Care’ $20 copayment 80% Specialist Services • Allergy Treatments Routine Gynecological Exam & Pap Test • $35 copayment 80% Well Child Care • Immunizations • Newborn Care Inpatient Hospital Care Unlimited Hospital Days (Semi-Private). Deductible per year then 80% Private Room When Medically Necessary• Medication & Drugs ‘ Nursing Care • Professional Services’ X-rays & Laboratory . Intensive/Coronary Care Radiation Therapy/Administrative of Blood Rx Card $10/25/45 Outpatient Facility Services X-ray & Laboratory $20 copayment 80% Ambulatory Surgery 80% 60% Short-Term Therapies Physical ‘Speech • Occupational • 20% coinsurance 80% Respiratory . Cardiac Rehabilitation Voluntary Family Planning Elective Sterilization, Male or Female $100 copayment 50% Infertility Services for the diagnosis of infertility 50% coinsurance None Skilled Nursing Facility Facility, supplies, and equipment authorized 8O% coinsurance 70% in lieu of acute care hospitalization Home Health Care Authorized in lieu of acute care hospitalization 80% coinsurance 70%

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