| Service |
Coverage Limits |
Prior Authorization |
Deductible |
Co-Insurance |
| Allergy Testing and Treatment |
Not Covered |
N/A |
N/A |
N/A |
| Ambulance (emergency only) |
Not Covered |
N/A |
N/A |
N/A |
| Ambulatory Surgical Center |
One Visit Counts as One of a Maximum of 2 Outpatient Services Annually |
Notice Required |
Applied |
15% of Allowed Charges |
| Chiropractor |
Not Covered |
N/A |
N/A |
N/A |
| Dental Care |
Not Covered |
N/A |
N/A |
N/A |
| Durable Medical Equipment |
Included as a Part of Inpatient or Outpatient Services or as the result of a Physician Visit |
No Notice Required |
Applied |
15% of Allowed Charges |
| Emergency Room Services |
One Visit Counts as One of a Maximum of 2 Outpatient Services Annually |
Notice Required |
Applied |
15% of Allowed Charges |
| Home Health |
Not Covered |
N/A |
N/A |
N/A |
| Immunizations |
Covered as a Part of Physician Services Visit |
No Notice Required |
None |
15% of Allowed Charges |
| Inpatient Hospital |
Covered up to seven days anually |
Notice Required |
Applied |
15% of Allowed Charges |
| Inpatient Mental or Behavioral Health Hospital |
Covered up to seven days anually |
Notice Required |
Applied |
15% of Allowed Charges |
| Laboratory And Xray |
Included as part of a covered Physician Services Visit or Outpatient or Inpatient Services Only |
No Notice Required |
None |
15% of Allowed Charges |
| Medical Supplies |
Included as part of a covered Inpatient or Outpatient Services or as the result of a Physician Visit |
No Notice Required |
Applied |
15% of Allowed Charges |
| Nurse Midwife |
One Visit Counts as One of a Maximum of 6 Physician Services Annually. Midwives must work under the direction of a participating plan physician. |
No Notice Required |
None |
15% of Allowed Charges |
| Outpatient Mental and Behavioral Health |
One Visit Counts as One of a Maximum of 2 Outpatient Services Annually |
Notice Required |
Applied |
15% of Allowed Charges |
| Physical Therapy |
One Visit Counts as One of a Maximum of 6 Physician Services Annually |
No Notice Required |
None |
15% of Allowed Charges |
| Physician Services |
One Visit Counts as One of a Maximum of 6 Physician Services Annually |
No Notice Required |
None |
15% of Allowed Charges |
| Podiatry |
Not Covered |
N/A |
N/A |
N/A |
| Prescription Drugs |
Maximum of Two Prescriptions per Month Per Year. Mail order prescriptions are not covered. |
No Notice Required |
None |
Copays $5 Generic/$15 Brand Preferred/$30 Non Brand Non-Preferred |
| Preventative Health Screenings |
Covered as a Part of Physician Services Visit or Outpatient Services |
No Notice Required |
None |
15% of Allowed Charges |
| Speech Therapy |
One Visit Counts as One of a Maximum of 6 Physician Services Annually |
No Notice Required |
None |
15% of Allowed Charges |
| Vision Care |
Glasses and Contacts are Not Covered. Vision Services related to Medical Issues that are non-corrective in nature are covered |
No Notice Required |
None |
15% of Allowed Charges |