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benefits and services





In-Network POS and Health Plan Summary of Benefits

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

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