|
BENEFITS
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|
Preventive Care
|
|
Routine Physical Exams – Adults
Well child care to age 19, including immunizations
Gynecological
Mammograms
|
No co-pay
No co-pay
$10 co-pay
No co-pay
|
|
Prescription
Drugs
|
|
Generic
Brand
Mail Order (up to a 90 day supply)
Contraceptives
|
$5 co-pay
$10 co-pay
$5 (generic), $10 (brand)
Covered
|
|
Outpatient
Care
|
|
Physician Office Visits
X-rays & Laboratory Tests (At participating Laboratories)
Physical and Occupational Therapy, up to 60 visits per lifetime
Chiropractic Care
Rehabilitation, 60 visits per lifetime
Speech Therapy, up to 60 visits per lifetime
Diagnostic Procedures and/or Surgery Performed in a Hospital
or Outpatient Surgical Care
Allergy Care
|
$10 co-pay
No co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
No co-pay
$10 co-pay
|
|
Inpatient Care
|
|
Hospitalization - Semi-Private Room and Board
Physicians’, Surgeons’ and Nursing Services and Medications
Restorative Physical & Occupational Therapy, up to 60
days lifetime
Skilled Nursing Facility, 30 days
|
No co-pay
No co-pay
No co-pay
No co-pay
|
|
Maternity Care
|
|
Pre-Natal & Post-Natal
Hospital
Services for Mother & Child (including all newborn costs
even if mother is discharged and newborn requires continued
hospitalization)
Infertility Treatments, $10,000 per lifetime
|
No co-pay
No co-pay
$10 co-pay for Office Visits
No co-pay for outpatient facility
|
|
Vision Care
|
|
Exams, every 12 months
Frames and Corrective lens every 24 months
|
$50 reimbursement
$70 reimbursement
|
|
Mental Health
|
|
Outpatient Visits, 30 visits per year
Inpatient, 30 days per year
|
50% co-pay per visit
No co-pay
|
|
Alcohol/Substance Abuse
|
|
Inpatient Detoxification, Up to 7 days per year
Outpatient Rehabilitation, 60 visits per 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 60 visits
Hospice Care, 210 days per lifetime (Inpatient or Outpatient)
|
$10 co-pay
Covered in full
|
|
Emergency Care
|
|
Emergency Room at Hospital
Urgent Care Facility
Ambulance
|
$25 co-pay
$10 co-pay
No co-pay
|
|
Other Benefits
|
|
Exercise Facility – per six months
|
$100 reimbursement– Subscriber
$50 reimbursement – Spouse
|
|
Preventive Dental Care, under age 12
|
No co-pay
|
Counties
Covered:
| State |
Counties |
| New
York |
Bronx,
Brooklyn, Dutchess, Kings, Nassau, Manhattan, Orange, Putnam,
Queens, Rockland, Staten Island, Suffolk and Westchester |
| New
Jersey |
Atlantic,
Bergen, Burlington, Camden, Cape May, Cumberland, Essex, Hudson,
Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris,
Ocean, Passaic, Salem, Somerset, Sussex, Union and Warren |
| Connecticut
|
Fairfield,
Hartford, Litchfield, Middlesex, New Haven, New London, Tolland
and Windham |
|