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BENEFITS
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Preventive Care
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Routine Physical Exams – Adults
Well child care to age 19, including immunizations
Gynecological
Mammograms
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$10 co-pay
No co-pay
$10 co-pay
No co-pay
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Prescription
Drugs
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Generic and Brand (Subject to Drug Formulary)
Mail Order (Up to 90 day supply)
Contraceptives
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$10 co-pay
Co-pays reduced by 50%
Covered
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Outpatient
Care
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Physician Office Visits (Private Office or HIP Center)
X-rays & Laboratory Tests
Physical and Occupational Therapy, up to 90 visits a year
Chiropractic Care
Cardiac Rehabilitation/Kidney Dialysis
Speech Therapy, up to 90 visits a year
Diagnostic Procedures and/or Surgery Performed in a Hospital
or Outpatient
Surgical Care
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$10 co-pay
No co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
No co-pay
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Inpatient Care
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Hospitalization - Semi-Private Room and Board
Physicians’, Surgeons’ and Nursing Services and Medications
Restorative Physical & Occupational Therapy, up to
90 days
Skilled Nursing Facility, unlimited days
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No co-pay
No co-pay
No co-pay
No co-pay
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Maternity Care
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Pre-Natal & Post-Natal (from effective date of HIP coverage)
Hospital
Services for Mother & Child (including all newborn costs
even if mother is discharged
and newborn requires continued hospitalization)
Family Planning
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No co-pay
No co-pay
Covered
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Vision Care
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Exams
Frames and Corrective lens for each family member covered
at participating vendor
Laser Vision Correction
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Covered
$45 co-pay
Discounted to $925 per eye
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Mental Health
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Outpatient Visits, 60 visits per year
Inpatient, 30 days per year
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No co-pay
No co-pay
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Alcohol/Substance Abuse
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Inpatient Detoxification, Up to 7 days per year
Outpatient Rehabilitation, 60 visits which include 20
family counseling visits/year
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No co-pay
$10 co-pay
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Home Health or Hospice Care
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Home HealthCare Visits and Service, up to 200 visits
Hospice Care, 210 days per lifetime
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No co-pay
No co-pay
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Emergency Care
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Emergency Room at Hospital
Urgent Care Facility
Ambulance
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No co-pay
$10 co-pay
No co-pay
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Other Benefits
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Dental Care and Preventive Dental, Every 6 months
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$10 co-pay
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Medical Supplies, Durable Medical Equipment
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No co-pay
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Wheelchairs
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Covered under DME rider
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Diabetes Equipment, supplies, and education
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$5 co-pay per month
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Alternative Medicine – Acupuncture, Yoga, and Massage
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Discount
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Fitness (Gym and Tennis Club)
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Discount
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