Plan A 5000 /Individual and Family Plan -$5 000 Deductible Non-Maternity Sumary of Benefits and Copayments for Plan A

   PROVIDER AND PREVENTINE SERVICES  

Periodic Well Physicals and Exams
Well Child Care and Pediatric Services
Primary Care Physician Services
Specialist Physician Services
Affordable Care Act Required Preventive Services
(Includes Mammograms and Pap Smears)
Health Education
Inmunizations
Podiatry Services
Chiropractic Services
Routine Vision and Hearing Examinations
Primary Care and Specialist Office Procedures




URGENT CARE AND SERVICES

EMERGENCY CARE AND SERVICES
(including hospital stays initiated
thorough ER and ambulance)

LABORATORY AND ROUTINE X-RAYS

INPATIENT HOSPITAL SERVICES
(Including physicians
services related
to treatment)

OUTPATIENT SURGERY/PROCEDURES:
.At Hospital
.At free-standing ambulatory surgery center

THERAPEUTIC AND DIAGNOSTIC PROCEDURES:
(Including physicians services related to treatment)
.At Hospital
.At free-standing facility

PRESCRIPTIONS: Generic prescription drugs
except brand prescriptions and
non-prescription medicines

MATERNITY AND NEWBORN SERVICES

OPTIONAL RIDERS AVAILABLE
Eyeglasses
Dental
   COPAYMENTS PLAN A  

$0 per visit*
$0 per visit*
$25 per visit*
$50 per visit*
$0 per visit*

$0 per visit*
$0 per visit*
$50 per visit*
$50 per visit*
$0 per visit*
No charge after regular office visit copay for
office-based surgeries, procedures and routine
laboratory and exams. Exceptions : Infusions and
Chemotherapy-Outpatient copays apply.

After normal business hours, $50 per visit

$100 copay plus 25% of all cost over $100
(Deducible applies to impatient portion)


$0 per visit

After deductible ,$500 per day for first 5 days
Minimun copays apply for certain intensive care
services .(If admitted through ER, see aplicable
ER copays above)

After deductible,$500 to $1500 copay
$500 to $1500 copay


After deductible,$500 to $1500 copay
$500 to $1500 copay



$10/$15/$20/$30 or 50% (per 30-day
supply) per prescription at contrated
Plan A PCP offices

Copayments and coinsurance applies


$10 copayment
See Dental Brochure
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