| Benefit |
Copay/Coinsurance*
(patient's responsibility) |
Status |
Notes |
| DENTAL CARE |
-- |
Not Covered
|
|
| VISION (OPTOMETRY) |
-- |
Not Covered
|
|
| GENERIC PRESCRIPTION DRUG |
$10.00 |
Active
|
Vendor: MEDIMPACT
|
| BRAND NAME PRESCRIPTION DRUG |
$20.00 |
Active
|
Vendor: MEDIMPACT
|
| PHARMACY |
$45.00 |
Active
|
Vendor: MEDIMPACT
|
| PHYSICAL MEDICINE |
$20.00 |
Active
|
|
| PSYCHIATRIC (MENTAL HEALTH) |
$20.00 |
Active
|
Limitation:
50 VISIT per 1 CALENDAR YEAR
$1,002.00 Lifetime Max
$1,005.00 Calendar Year Max
|
| PSYCHOTHERAPY |
$20.00 |
Active
|
Limitation:
50 VISIT per 1 CALENDAR YEAR
|
| PSYCHIATRIC - INPATIENT |
$100.00/20% |
Active
|
Limitation:
73 DAYS per 1 CALENDAR YEAR
|
| PSYCHIATRIC - OUTPATIENT |
$20.00 |
Active
|
Limitation:
50 VISIT per 1 CALENDAR YEAR
|
| MEDICAL CARE |
$20.00 |
Active
|
|
| XRAY |
10% |
Active
|
|
| CHIROPRACTIC |
$20.00 |
Active
|
|
| HOSPITAL |
20% |
Active
|
|
| HOSPITAL INPATIENT |
$100.00/20% |
Active
|
Limitation:
120 DAYS and $5,000.00 per 1 CALENDAR YEAR
|
| HOSPITAL OUTPATIENT |
20% |
Active
|
|
| HOSPITAL EMERGENCY MEDICAL |
$100.00/20% |
Active
|
|
| WELL BABY CARE |
0% |
Active
|
|
| ROUTINE PHYSICAL |
0% |
Active
|
|
| EMERGENCY SERVICES |
$40.00 |
Active
|
|
| PROFESSIONAL (SPECIALIST) |
$20.00 |
Active
|
|
| OFFICE VISIT |
$20.00 |
Active
|
|
| PRIMARY CARE PHYSICIAN |
$20.00 |
Active
|
|
