BENEFITS

Preventive Care

Routine Physical Exams – Adults and children
Immunizations
Gynecological

$10 co-pay

$10 co-pay
$10 co-pay

Prescription Drugs

Generic
Brand
Formulary
Mail Order (up to a 90 day supply)
Contraceptives

$10 co-pay
$15 co-pay
$30 co-pay
$20/$30/$60 co-pay
Covered

Outpatient Care

Physician Office Visits
X-rays & Laboratory Tests
Physical and Occupational Therapy, Including Chiropractic Care
Speech Therapy
Diagnostic Procedures and/or Surgery Performed in a Hospital or Outpatient        Surgical Care

$10 co-pay, after hours $15 co-pay
$10 co-pay
$10 co-pay
$10 co-pay

No co-pay

Inpatient Care

Hospitalization - Semi-Private Room and Board
Physicians’, Surgeons’ and Nursing Services and Medications
Restorative Physical & Occupational Therapy

No co-pay

No co-pay

$10 co-pay

Maternity Care

Pre-Natal & Post-Natal (from effective date of Aetna coverage)

Hospital Services for Mother & Child (including all newborn costs even if  mother is discharged and newborn requires continued hospitalization)

$10 co-pay First visit


No co-pay

Vision Care

Routine Eye Exam
Allowances for frames, glasses, and lens

$10 co-pay
$100 reimbursement every 24 months

Mental Health

Outpatient Visits, 20 visits per year
Inpatient, 35 days

$25 co-pay
No co-pay

Substance Abuse

Detoxification
Outpatient Rehabilitation, 60 visits

No co-pay
$10 co-pay

Home Health or Hospice Care

Physicians House calls

$15 co-pay

Emergency Care

Emergency Room (co-pay waived if admitted)

$35 co-pay

Other Benefits

Pediatric Preventive Dental Exam

$10 co-pay