Abortion Services

$100 co-payment

Community Health Center Visits
• Primary Care Provider (PCP)
• Specialist

$15 co-payment
$22 co-payment

Office Visits
• Primary Care Provider (PCP)
• Specialist
• Eye Care (vision care)

$15 co-payment
$22 co-payment
$20 co-payment

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.

Diabetic Specialty Care

$20 co-payment

Co-payment is for services diabetic members get from a specialist (other than routine services a podiatrist provides, see Podiatry)

Outpatient Surgery
(outpatient hospital/ambulatory surgery centers)

$125 co-payment

Laboratory Services

No co-payment

Radiology Services

No co-payment

Authorization required for some services

High-cost Imaging Services
(MRI, CT, PET)

$60 co-payment

Prior authorization required

Inpatient Medical Care
Room and Board (includes deliveries/surgeries/radiology services/labs)

$250 co-payment

Co-payments waived if transferred from another inpatient unit
Inpatient medical care covered according to medical necessity and subject to prior authorization

Medication via Pharmacy

$12.50 generic and select over-the-counter drugs (Tier 1)

$25 preferred brand-name drugs (Tier 2)

$50 nonpreferred brand-name drugs (Tier 3)

1-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
10% of cost for diabetes and asthma supplies

Medication via Mail

$25 generic and select over-the-counter drugs
(Tier 1)

$50 preferred brand-name drugs (Tier 2)

$150 nonpreferred brand-name drugs (Tier 3)

3-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
10% of cost for diabetes supplies

Emergency Care

$100 co-payment

Co-payment waived if admitted to an inpatient unit of a hospital

Inpatient Mental Health and/or Substance Abuse

$250 co-payment

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

Outpatient Mental Health and/or Substance Abuse
Methadone Treatment (dosing, counseling, labs)

$15 co-payment

No co-payment

After 26 visits per benefit year (July 1 – June 30), prior authorization required

No co-payments for methadone-related services

Cardiac Rehabilitation

No co-payment

Requires prior authorization

Home Health Care

No co-payment

Requries prior authorization

Inpatient Skilled Nursing Facility (SNF)

No co-payment

Maximum of 100 calendar days total per benefit year (July 1 – June 30) at either (or at a combination of) inpatient skilled nursing facility or inpatient rehabilitation hospital
Co-payment waived if transferred from another inpatient unit

Inpatient Rehabilitation Hospital or Chronic Disease Hospital

$250 co-payment

Short-term Outpatient Rehabilitation

$20 co-payment

Maximum of 20 sessions (combined) of physical therapy, occupational therapy, and speech therapy with prior authorization; additional sessions require medical review and prior authorization

Physical/Occupational/Speech Therapy

$20 co-payment

Ground Ambulance

No co-payment

Emergency transport only; nonemergency transport covered if medically necessary and with prior authorization

Durable Medical Equipment (DME)

10% of cost

Requires prior authorization

Supplies

10% of cost

Doesn't require prior authorization

Prosthetics

10% of cost

Requires prior authorization

Oxygen and Respiratory Therapy Equipment

10% of cost

Requires prior authorization

Hospice

No co-payment

Requires prior authorization

Orthotics

No co-payment

Requires prior authorization; shoe inserts for diabetics only

Podiatry

$20 co-payment (nonroutine diabetic)
$22 co-payment (nondiabetic)
$10 co-payment

Medically necessary nonroutine foot care covered


Routine foot care services for diabetics only

Vision

$20 co-payment (optometrist)
$22 co-payment (ophthalmologist)

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.

Wellness
• Family Planning
• Nutrition Counseling
• Prenatal Care
• Nurse Midwife

No co-payment
No co-payment
No co-payment
No co-payment

Doesn't require prior authorization
Requires prior authorization
Doesn't require prior authorization
Doesn't require prior authorization

Yearly Co-payment Maximum per Benefit Year per Member

Pharmacy
All other
co-payments

$800
$1,500