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Major Medical: Services
| In-Network | Out-of-Network | |
|---|---|---|
|
COINSURANCE |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
TELADOC |
No charge to member. |
Not covered. |
|
PREVENTATIVE CARE BENEFITS |
||
|
Well Child Services3 |
Plan pays: 80% Your responsibility: 20% |
Not Covered |
|
Routine Colonoscopy4 |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
Annual Routine PSA5 |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
Annual OB/GYN Exam6 |
Plan pays: 80% Your responsibility: 20% |
Not covered. |
|
Annual Routine Pap Smear7 |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
Mammogram8 |
Plan pays: 80% Your responsibility: 20% |
Plan pays: 60% Your responsibility: 40% |
|
PRESCRIPTION DRUG COVERAGE Unlimited Calendar Year Maximum Per Member |
||
|---|---|---|
|
Generic 30 day supply |
Plan pays all but copayment Your responsibility: $4 copayment9 |
Plan pays 60% Your responsibility: 40% |
|
Brand
|
Plan pays: 80% Your responsibility: 20% |
Plan pays 60% Your responsibility: 40% |
FOOTNOTES
3 Benefits are available, subject to deductible and coinsurance, for a member under the age of seven for physical examinations and appropriate immunizations/vaccinations when services are rendered by an in-network provider. Exams not used during the time periods below do not carry over to the next time period.
| Age | Number of Exams |
|---|---|
| Under age one | four exams from birth to the child's first birthday |
| Age one | two exams from the child's first birthday to the child's second birthday |
| Age two through six | one exam per year (determined by the child's birthday) |
4 Benefits will be provided for one routine colonoscopy every 10 years for members age 45 and over when provided by an in-network or out-of-network provider, subject to the deductible and coinsurance.
5 Benefits will be provided, subject to deductible and coinsurance, for one routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.
6 Benefits will be available for one routine OB/GYN exam per calendar year, subject to deductible and coinsurance. Services must be rendered by an in-network physician’s office and billed by the in-network provider. Related pathology, including pap smear, which is provided as a part of the routine OB/GYN exam, will be covered when the services are rendered by an in-network physician’s office and billed by the in-network provider. Related pathology that the physician sends to an independent laboratory will be subject to deductible and coinsurance. No benefit is available for routine OB/GYN exams provided by an out-of-network provider.
7 Benefits will be provided for the interpretation of one routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting, subject to deductible and coinsurance.
8 Benefits will be provided, subject to deductible and coinsurance, for routine mammography screening provided such examinations are conducted upon the recommendation of the member’s physician. One baseline routine mammogram will be allowed for members between the ages of 35-39. One routine mammogram will be allowed annually for members age 40 and above. All routine mammography screens are subject to deductible and coinsurance.
9 Prescription copayment does not apply toward deductible or out-of-pocket maximum.