Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip

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1 HOSPITAL SERVICES Hospital Inpatient : Paid in full, Non-network: Hospital charges subject to 10% of billed charges up to coinsurance maximum. Non-participating provider charges subject to Basic Medical Program. Lesser of $200 or 20% (surgery) No cost No cost No cost Hospital Outpatient Hospital/: $40 or $60 per visit;hospital/non-participating Provider: Hospital charges $40 or $60 per visit. Non-participating provider charges subject to BasicMedical;NonnetworkHospital/Non-participating Provider: Hospital charges subject to $90 (may be less for non-surgical) 10%of billed charges or a $75 copayment, whichever is greater up to coinsurancemaximum. Non-participating Provider charges subject to BasicMedical $10 per visit $150 max depending on location $120 max depending on location Ambulance No copayment if service is provided by admitting hospital. $35 $100/trip $50/trip $75/trip $50/trip Emergency Room $60 or $70/visit No copayment. $100/visit $50/visit $75/visit $75/visit Urgent Care $15 or $20/visit $35/visit $10/visit $50/visit $25/visit Skilled Nursing Facility No cost up to 365 benefit days. No benefit if Medicare primary. No cost: 45 days per admission up to a maximum of 360 lifetime limit No cost up to 50 days No cost up to 45 days No cost up to 45 days Hospice No cost; unlimited No cost; 210 days No cost; unlimited No cost; unlimited No cost; 210 days Page 1

2 PHYSICIAN SERVICES Office Visit $15 or $20/visit $25/visit, no cost annual exam or well child $10/visit; no cost for well child care $20/visit, no cost for well child visits $25/visit; $10 PCP sick visits for children to age 25 Specialty Office Visit $15 or $20/visit $40/visit $10/visit $20/visit $40/visit Annual Routine Physical $15 or $20/visit No Cost $10/visit No Cost No Cost Allergy Testing / Treatment $15 or $20/visit Contact carrier Contact carrier Contact carrier Contact carrier Chiropractic $15 or $20/visit $40/visit $10/visit $20/visit $40/visit Family Planning $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Infertility Services $40 Outpatient $15 or $20/visit; no cost at designated Center of Excellence; $50,000 lifetime maximum $40/visit $10/visit $20/visit (physician's office), $75/visit (outpatient surgery center) $25/visit Page 2

3 Contraceptive Drugs/ Devices $15 or $20/visit. Also covered by prescription drug program subject to copayment. Applicable prescription copay applies Applicable prescription copay applies. Applicable prescription copay applies No cost WOMEN'S HEALTH CARE Pap Tests $40/outpatient visit $15 or $20/visit No cost for routine visit No cost No cost No cost Mammograms $40/outpatient visit $15 or $20/visit No cost for routine visit No cost No cost No cost Pre/Post Natal No cost $5 for the first 10 visits No cost No cost $25 copayment per pregnancy Bone Density Tests $40/outpatient visit $15 or $20/visit No cost for routine visit $10/visit No cost No cost DIAGNOSTIC / THERAPEUTIC SERVICES X-Rays $40/outpatient visit $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Lab Tests $40/outpatient visit $15 or $20/visit $25/visit No cost $20/visit No cost Page 3

4 Pathology No Cost $15 or $20/visit $25/visit No cost $20/visit No cost EKG/EEG $40/outpatient visit $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Radiation / Chemo No Cost No cost Radiation $25/Chemo $50 $10/visit $20/visit Radiation $40/visit; Chemotherapy $40/visit MENTAL HEALTH / SUBSTANCE ABUSE Inpatient Mental Health No cost; unlimited when medically necessary (OptumHealth) No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Mental Health $15 or $20/visit; unlimited when medically necessary (OptumHealth) $40/visit; unlimited $10/visit; unlimited $20/visit; unlimited $25/visit; unlimited Page 4

5 Inpatient Drug / Alcohol Rehab No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Drug / Alcohol Rehab $15 or $20/visit to approved program; unlimited when medically necessary (OptumHealth) $25/visit; unlimited $10/visit; unlimited $20/visit; unlimited $25/visit; unlimited PRESCRIPTION DRUGS Prescription Drugs *Note: 3-tier system (generic, preferred brandname drugs, and nonpreferred brand-name drugs) Mail order OR retail pharmacy, 30 day supply: $5, $15, or $40. Mail order day supply: $5, $20, or $65. Pharmacy day supply: $10, $30, or $70. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name copayment plus the difference in cost between the brand-name drug and its generic equivalent. $10/$30/$ days mail order: $20/$60/$100. Open formulary. $5/$15/$ days mail order: $15/$45/$105. $5/$15/$ days mail order: day copayments $10/$30/$ days mail order: $25 generic/$75 brand/$125 non-formulary. Open formulary MISCELLANEOUS Centers of Excellence for Cancer and/or Transplant No cost at designated Centers of Excellence. Precertification required. N/A N/A N/A N/A Page 5

6 Diabetic Supplies No cost. Call HCAP for participating providers. $25/item; 30 day supply $10/item $20/item $25 copayment per boxed item/31 day supply Home Health Care No cost. Call HCAP for participating providers. Contact carrier Contact carrier $20/visit, max 40 visits Contact carrier Durable Medical Equipment No cost. Call HCAP for participating providers. 50% coinsurance 20% coinsurance 50% coinsurance 50% coinsurance Orthotics Paid in full 50% coinsurance 20% coinsurance No cost 50% coinsurance Prosthetics Paid in full. 50% coinsurance 20% coinsurance No cost 50% coinsurance Rehabilitative Care (PT, OT, Speech) Inpatient: no cost; $15 or $20/visit for PT following surgery or hospitalization $15 or $20/visit Inpatient: no cost up to 60 days. Outpatient: $40/visit up to 30 visits combined for: PT, Speech and OT Inpatient: no cost up to 45 days. Outpatient: $10/visit; max 20 visits. Inpatient: No cost up to 45 days. Outpatient: $20/visit up to 20 visits per year Inpatient: no cost, two month max; Outpatient: $40/visit up to 30 visits Alternative Medicine: Nutrition, Acupuncture, Massage Therapy Discount for network provider Contact carrier - Discounts available Contact carrier - Discounts available Contact carrier - Discounts available Each policy receives $100 to spend on health, wellness, and fitness programs. Contact for additional programs. Page 6

7 Dental (preventive) Not covered Not covered Preventive: 20% discount at select providers; free second annual exam $50/cleaning; 20% discount on additional services at select providers $25/visit for children up to 19 Hearing Aids up to $1200 or $1500 per aid per ear every 4 years (every 2 years for children). Covered in full every three years for children Not covered under 19. Discounts Available at select providers Not covered Vision (routine) Not covered $40/exam associated with disease or injury. Discount from participating providers $10/visit once/year. $25/exam every 24 months Page 7

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