Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Your PCP, OB/GYN physician, network nurse practitioner or nurse midwife • Other network providers $20 per visit, no deductible $60 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible Mental health or substance abuse treatment $10 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Your PCP or OB/GYN physician • Other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) in: • Other general hospitals (as many days as medically necessary) • Higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many ...
