Primary Care Visit
$20.00 Copay
80.00% Coinsurance after deductible
Specialist Visit
$50.00 Copay
80.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$20.00 Copay
80.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
80.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
$250.00 Copay
20.00% Coinsurance after deductible
$250.00 Copay
80.00% Coinsurance after deductible
Generic Drugs
$10.00 Copay
$10.00 Copay
Preferred Brand Drugs
$30.00 Copay
$30.00 Copay
Non-Preferred Brand Drugs
$50.00 Copay after deductible
$50.00 Copay after deductible
Specialty Drugs
30.00% Coinsurance after deductible
30.00% Coinsurance after deductible
Outpatient Facility Fee
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Emergency Room Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Emergency Transportation/Ambulance
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Urgent Care
$20.00 Copay
80.00% Coinsurance after deductible
Inpatient Hospital Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
$20.00 Copay
80.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$20.00 Copay
80.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Prenatal and Postnatal Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Home Healthcare Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Outpatient Rehabilitation Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Habilitation Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Skilled Nursing Facility
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Durable Medical Equipment
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Hospice Services
No Charge
80.00% Coinsurance after deductible
Chiropractic Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Well Baby Visits and Care
No Charge
80.00% Coinsurance after deductible
Allergy Testing
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Diabetes Education
$20.00 Copay
80.00% Coinsurance after deductible
Nutritional Counseling
No Charge
80.00% Coinsurance after deductible
Accidental Dental
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered