What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Habilitative Services - Outpatient
Manipulative treatment services
$25 copay
50%*
Other habilitative services
No copay*
50%*
Limits will be the same as, and combined with those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.
Home Health Care¹
No copay*
50%*
Limited to 30 visits per year. One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion.
Lab, X-Ray and Diagnostic - Outpatient - Lab Testing¹
No copay*
50%*
Limited to 18 Definitive Drug Tests per year. Limited to 18 Presumptive Drug Tests per year.
Lab, X-Ray and Diagnostic - Outpatient - X-Ray and other Diagnostic Testing¹
No copay*
50%*
Major Diagnostic and Imaging - Outpatient¹
No copay*
50%*
Physician Fees for Surgical and Medical Services
No copay*
50%*
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
Manipulative treatment services
$25 copay
50%*
Other rehabilitation services
No copay*
50%*
Limited to 20 visits of Manipulative Treatments per year. Limited to 30 combined visits of physical therapy, occupational therapy, speech therapy, cardiac therapy, post cochlear therapy, cognitive therapy and pulmonary therapy per year. Limits are combined with Habilitative Services - Outpatient.
Surgery - Outpatient¹
No copay*
50%*
Therapeutic Treatments - Outpatient¹
No copay*
50%*
Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, intravenous infusion, medical education services and radiation oncology. Supplies and Services
Diabetes Self-Management Items¹
The amount you pay is based on where the covered health care service is provided under Durable Medical Equipment (DME), Orthotics and Supplies or in the Prescription Drug Benefits Section.
Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care¹
The amount you pay is based on where the covered health care service is provided.
Durable Medical Equipment (DME), Orthotics and Supplies¹
No copay*
50%*
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
4
Made with FlippingBook flipbook maker