BENEFITS

Preventive Care

Routine Physical Exams – Adults
Well child care to age 19, including immunizations
Gynecological (No PCP Referral)
Mammograms, Cervical Cancer Screening

$10 co-pay
No co-pay

$10 co-pay
No co-pay

Prescription Drugs

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

$10 co-pay
$20 co-pay
$30 co-pay
$10/$20/$30 per 30 day supply
Covered

Outpatient Care

Physician Office Visits (PCP or Specialist)
X-rays & Laboratory Tests
Physical and Occupational Therapy, up to 30 visits a year
Chiropractic Care
Cardiac Rehabilitation/Kidney Dialysis
Allergy Services
Speech Therapy, up to 30 visits a year
Diagnostic Procedures and/or Surgery Performed in a Hospital or Outpatient Surgical Care

$10 co-pay
No co-pay
$10 co-pay

$10 co-pay
No co-pay
$10 co-pay (waived for treatments)
$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, up to 30 days
Skilled Nursing Facility, up to 60 days per year

No co-pay

No co-pay

No co-pay

No co-pay

Maternity Care

Pre-Natal & Post-Natal (from effective date of BC/BS coverage)

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

No co-pay


No co-pay

Vision Care

Exams, Frames and Corrective lens every 24 months

Co-pay based on plan fee schedule

Mental Health

Outpatient Visits, 20 visits per year
Inpatient, 30 days per year

$25 co-pay per visit
No co-pay

Alcohol/Substance Abuse

Inpatient Detoxification, Up to 7 days per year
Outpatient Rehabilitation, 60 visits which include 20 family counseling visits/year
Inpatient Rehabilitation, 30 days per year

No co-pay
No co-pay

No co-pay

Home Health or Hospice Care

Home HealthCare Visits and Service, up to 200 visits/year covered in full
Hospice Care, 210 days per lifetime

No co-pay

Covered in full

Emergency Care

Emergency Room (co-pay waived if admitted within 24 hours)
Ambulance (Air Ambulance)

$35 co-pay

No co-pay

Other Benefits

Medical Supplies, Durable Medical Equipment

No co-pay

Prosthetics & Orthotics

No co-pay