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Medical Plan

2017 Preventive Services
You Pay:
Preventive care services for adults age 19 and older including the preventive services recommended by the U.S. Preventive Services Taskforce. Services include but are not limited to:
  • Visits or exams for preventive care, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC, fasting lipid profile, cholesterol tests and metabolic and general health panel tests
  • Preventive screenings: Pap smears, mammograms, colorectal cancer tests, prostate cancer tests, STD screenings, genetic counseling in certain situations, and related office visits
Nothing for covered services
Routine immunizations for adults age 19 and older [as licensed by the U.S. Food and Drug Administration (FDA)], limited to:
  • Hepatitis (Types A and B)
  • Herpes Zoster (shingles)
  • Human Papillomavirus (HPV)
  • Influenza (flu)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus-diphtheria, pertussis booster (one every 10 years)
  • Varicella (chickenpox)
*These vaccines are also covered by your Pharmacy benefits when provided by pharmacies.
Nothing for covered services
Preventive care services for children up to age 19, including preventive services recommended under the Affordable Care Act and the American Academy of Pediatrics. These services include but are not limited to visits or exams for preventive care, routine hearing and vision screenings, laboratory tests, immunizations, and nutritional counseling. Nothing for covered services
2017 Professional Provider’s Care
Office visits and outpatient consultations $25 office visit Copayment for primary care provider
$50 office visit Copayment for specialist
Routine exams and other preventive care services Nothing for covered services
Surgical care $800 Deductible
20% Coinsurance
2017 Medical Emergency
Surgical care $200 Copayment for Emergency Department visit
Urgent care $50 Copayment for urgent care center
2017 Hospital/Facility Care
Hospital Inpatient $800 Deductible
20% Coinsurance
Outpatient hospital/facility care $800 Deductible
20% Coinsurance
2017 Maternity Care
Obstetrical care performed by a physician or nurse midwife, such as prenatal care (including ultrasound, lab and diagnostic tests), delivery, postpartum care $800 Deductible
20% Coinsurance
Inpatient hospital
Precertification is not required. Note: you may stay in the hospital for up to 48 hours after a regular delivery and 96 hours after a c-section. We will cover a longer stay if medically necessary; precertification is required for any inpatient stay beyond these time frames.
$800 Deductible
20% Coinsurance
2017 Mental Health and Substance Abuse
Inpatient Hospital/Facility $800 Deductible
20% Coinsurance
Outpatient Hospital/Facility Care $800 Deductible
20% Coinsurance
Office visits $25 office visit Copayment
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