Medical Services	10 & 10E*	15 & 15E*	20 & 20E*
Office Visits / Specialist Visits, Preventive Care, Physical Exams, Well Baby / Child Care, Immunizations, Eye Exams, Hearing Exams, X-rays / Lab tests, Annual gynecological exams, Mammography exams for women ages 35 & over and as perceived necessary by PCP prior to age 35, Maternity office visits, Pre-Admission Medical Testing Services.	$10 Co-Payment (waived for well child exams from birth to age 19)	$15 Co-Payment (waived for well child exams from birth to age 19)	$20 Co-Payment (waived for well child exams from birth to age 19)
Specialty Care Services (upon referral by PCP) including chiropractic and podiatry care, Surgeons and Anesthesiologists.	$10 Co-Payment	$15 Co-Payment	$20 Co-Payment
Second Opinions at your request	$10 Co-Payment	$15 Co-Payment	$20 Co-Payment
Second Opinions at our request	No Co-Payment	No Co-Payment	No Co-Payment
Physical Therapy, Speech Therapy and Occupational Therapy - 20 outpatient visits, 30 inpatient days per diagnosis per year.	No Co-Payment	No Co-Payment	No Co-Payment
Hospital Services:
Surgeon & Physician Fees, Semi Private Room (private if medically necessary), Operating and Recovery Room Fees, Intensive and Special Care Units, X-rays / Lab tests, Anesthesia, Prescribed Drugs, Nursing Services	$250* Co-payment	$250* Co-payment	$250* Co-payment
		* No Hospital Co-Payment for Plans 10E, 15E or 20E
Maternity Care	$10 Co-payment for pre-natal visits	$15 Co-payment for pre-natal visits	$20 Co-payment for pre-natal visits
Delivery & care of Mother and Baby Physician's Hospital Visits - Well Baby Nursery Care	$250* Co-payment for inpatient delivery	$250* Co-payment for inpatient delivery	$250* Co-payment for inpatient delivery
		* No Hospital Co-Payment for Plans 10E, 15E or 20E
Emergency Care	$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable	$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable	$50 Co-payment - Waived if member is admitted, however in-patient *co-payment is still applicable
Ambulance (limited to Emergency conditions unless approved in advance by the Plan)	No Co-payment	No Co-payment	No Co-payment
		* No Hospital Co-Payment for Plans 10E, 15E or 20E
Skilled Nursing Care Facility - limit of 45 days per calendar year	No Co-payment	No Co-payment	No Co-payment
Home Health Care - limit of 60 visits per calendar year	No Co-payment	No Co-payment	No Co-payment
Hospice Services - limit of 210 days per calendar year, including 5 bereavement visits	No Co-payment	No Co-payment	No Co-payment
Durable Medical Equipment	No Co-payment	No Co-payment	No Co-payment
Mental Health Services:
Outpatient - up to 20 visits per calendar year for short term evaluation and therapy	$25 Co-payment	$25 Co-payment	$25 Co-payment
Inpatient - up to 30 days of acute inpatient psychiatric care per calendar year as well as 20 inpatient hospital visits	$250* Co-payment	$250* Co-payment	$250* Co-payment
		* No Hospital Co-Payment for Plans 10E, 15E or 20E
Substance Abuse Services:
Outpatient - 60 visits per calendar year for diagnostic and treatment services, of which 20 visits may be used for Family Therapy	$10 Co-payment	$15 Co-payment	$20 Co-payment
Inpatient Detoxification - 7 days
		* No Hospital Co-Payment for Plans 10E, 15E or 20E