Plan A/Non-Grandfathered Plans– Adult Only Sumary of Benefits and Copayments for Plan A

     OUTPATIENT SERVICES      

Primary Care Physician Services
Specialist Physician Services
Sub-Specialist Physician Services
Surgical Services
Treatment rooms and all appropriate equipment
Application, changes, removal of dressings,
splints, plaster cast and removal of sutures
Medical supplies for use at Provider’s Office/Facility
Laboratory examinations and services
Periodic physical examinations
Well child care and pediatric services
Affordable Care Act Required Preventive Services
Health Education
Immunizations
Allergy testing
Allergy Visits & Immunotherapy
Podiatry services
Chiropractic Services
Routine Vision and Hearing Examinations
Therapeutic and Diagnostic Services
Major Procedures and Surgeries

INPATIENT HOSPITAL SERVICES

Semi-private room, board, nursing care, and meals
Intensive, critical, special and coronary care units
Operating, treatment and recovery rooms
Application, change and, removal of dressings,
splints, plaster casts and removal of sutures
Drugs, medicine, intravenous injections and solutions
prescribed by attending Physician for use in the hospital
Medical supplies for use in the hospital
Oxygen and its administration
Laboratory examinations, electrocardiograms and inhalation
therapy

MATERNITY AND NEWBORN SERVICES

URGENT SERVICES AND CARE, after regular office
hours

EMERGENCY SERVICES AND CARE, and
Hospital Stays initiated through the emergency
room, including emergency ambulance services
PRESCRIPTIONS

Generic Prescription Drugs except non-generic, non-
prescriptions and contraceptives

OPTIONAL RIDERS AVAILABLE


Coverage for Eyeglasses
Dental
   CO-PAYMENTS PLAN A      

$5 per visit**
$10 per visit
$50 per visit
No Charge
No Charge
No Charge

No Charge
No Charge**
No Charge**
No Charge**
No Charge**
No Charge**
No Charge**
$50 per visit
$10 per visit
$10 per visit
$10 per visit
$0 per visit**
*Co-payment
*Co-payment



No Charge
*Copayment
No Charge
No Charge

No Charge

No Charge
No Charge
No Charge


Not Covered

$40 per visit


$100 per Emergency plus 25 percent of
charges above $100



$10/$15/$20/$30 or 50%
per prescription at contracted Plan A PCP Offices



$10 Co-payment
See Dental Brochure
Comments