OUTPATIENT MEDICAL CARE
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Abortion Services
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$50 co-payment
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Community Health Center Visits
• Primary Care Provider (PCP)
• Specialist
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$10 co-payment
$18 co-payment
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Office Visits
• Preventive care services (inclusive of family planning visits)
• Non-preventive office visits
• Primary Care Provider (PCP)
• Specialist
• Eye Care (vision care)
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No co-payment
$10 co-payment
$18 co-payment
$10 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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$10 co-payment
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Co-payment is for services diabetic members get from a specialist (other than routine services a podiatrist provides, see Podiatry)
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Outpatient Surgery
(outpatient hospital/ambulatory surgery centers)
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$50 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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$30 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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$50 co-payment
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Co-payments waived if transferred from another inpatient unit
Inpatient medical care covered according to medical necessity and subject to prior authorization
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PHARMACY
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Medication via Pharmacy
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$10 generic and select over-the-counter drugs (Tier 1)
$20 preferred brand-name drugs (Tier 2)
$40 nonpreferred brand-name drugs (Tier 3)
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1-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
Supplies for diabetes and asthma are covered and don’t have a co-payment.
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Medication via Mail
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$20 generic and select over-the-counter drugs (Tier 1)
$40 preferred brand-name drugs (Tier 2)
$120 nonpreferred brand-name drugs (Tier 3)
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3-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
Supplies for diabetes are covered 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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$50 co-payment
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Co-payment waived if admitted to a hospital's inpatient unit
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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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$50 co-payment
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Inpatient mental health and/or substance abuse services covered according to medical necessity and subject to prior authorization
Co-payment waived if transferred from another inpatient unit
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Outpatient Mental Health and/or Substance Abuse
Methadone Treatment (dosing, counseling, labs)
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$10 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
Co-payment waived if transferred from another inpatient unit
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Inpatient Rehabilitation Hospital or Chronic Disease Hospital
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$50 co-payment
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Short-term Outpatient Rehabilitation
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$10 co-payment
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Maximum of 20 sessions (combined) of physical therapy, occupational therapy, and speech therapy with prior authorization; additional sessions require medical review and prior authorization
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Physical/Occupational/Speech Therapy
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$10 co-payment
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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 diabetics only
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Podiatry
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$18 co-payment (non-diabetic)
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Medically necessary non-routine foot care covered
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• People with diabetes
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$10 co-payment (non-routine diabetic)
$5 co-payment
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Routine foot care services for diabetics only
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Vision
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$10 co-payment (optometrist)
$18 co-payment (ophthalmologist)
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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 $500
All other co-payments $750
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