OUTPATIENT MEDICAL CARE
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Abortion Services
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No co-payment
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Community Health Center Visits
• Primary Care Provider (PCP)
• Specialist
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No co-payment
No co-payment
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Office Visits (preventive and non-preventive services)
• Primary Care Provider (PCP)
• Specialist
• Eye Care (vision care)
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No co-payment
No co-payment
No co-payment
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Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame up to a maximum credit of $80.
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Diabetic Specialty Care
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No co-payment
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Outpatient Surgery
(outpatient hospital/ambulatory surgery centers)
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No co-payment
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Laboratory Services
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No co-payment
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Radiology Services
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No co-payment
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Prior authorization required for some services
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High-cost Imaging Services
(MRI, CT, PET)
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No co-payment
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Prior authorization required
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INPATIENT MEDICAL CARE
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Inpatient Medical Care
Room and Board (includes deliveries/surgeries/radiology services/labs)
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No co-payment
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Inpatient medical care covered according to medical necessity and subject to prior authorization
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PHARMACY
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Pharmacy
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$1 generic and select over-the- counter drugs for diabetes, high blood pressure, and high cholesterol (Tier 1)
$3.65 generic and select over-the-counter drugs (Tier 1)
$3.65 brand-name drugs (Tier 2)
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1-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter drugs may be covered with a prescription.
Supplies for diabetes and asthma are covered with a prescription and don’t have a co-payment.
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Contraceptives
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No co-payment
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EMERGENCY CARE
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Emergency Care
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No co-payment
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MENTAL HEALTH AND/OR SUBSTANCE ABUSE
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Inpatient Mental Health and/or Substance Abuse
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No co-payment
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Inpatient mental health and/or substance abuse services covered according to medical necessity and subject to prior authorization
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Outpatient Mental Health and/or Substance Abuse
Methadone Treatment (dosing, counseling, labs)
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No co-payment
No co-payment
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After 26 visits per benefit year (January 1 – December 31), prior authorization required
No co-payments for methadone-related services
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REHABILITATION SERVICES
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Cardiac Rehabilitation
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No co-payment
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Requires prior authorization
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Home Health Care
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No co-payment
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Requires prior authorization
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Inpatient Skilled Nursing Facility (SNF)
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No co-payment
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Maximum of 100 calendar days total per benefit year (January 1 – December 31) at either (or at a combination of) an inpatient skilled nursing facility or an inpatient rehabilitation hospital; requires prior authorization
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Inpatient Rehabilitation Hospital or Chronic Disease Hospital
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No co-payment
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Short-term Outpatient Rehabilitation
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No co-payment
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Requires prior authorization
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Physical/Occupational/Speech Therapy
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No co-payment
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Requires prior authorization
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OTHER BENEFITS
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Ground Ambulance
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No co-payment
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Emergency transport only; nonemergency transport covered if medically necessary and with prior authorization
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Durable Medical Equipment (DME)
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No co-payment
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Requires prior authorization
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Supplies
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No co-payment
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Prosthetics
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No co-payment
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Requires prior authorization
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Oxygen and Respiratory Therapy Equipment
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No co-payment
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Requires prior authorization
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Hospice
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No co-payment
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Requires prior authorization
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Orthotics
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No co-payment
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Requires prior authorization; shoe inserts for people with diabetes only
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Podiatry
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No co-payment
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Medically necessary non-routine foot care covered; routine foot care services for people with diabetes only
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Vision
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No co-payment
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Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame up to a maximum credit of $80.
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Wellness
• Preventive visits
• Contraceptives
• Family Planning
• Nutrition Counseling
• Prenatal Care
• Nurse Midwife
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No co-payment
No co-payment
No co-payment
No co-payment
No co-payment
No co-payment
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Requires prior authorization
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CO-PAYMENT MAXIMUMS
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Yearly Co-payment Maximum per Benefit Year per Member
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Pharmacy $250
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