Routine physicals-One per plan year for adults; periodic for children, or as directed by the primary care physician
$30 or $40
Diagnostic x-rays, mammography, and lab tests
No copayment
Immunizations - For Children 0 to 6 years of age
No copayment
Immunizations - For children 7 years and older, and adults
$30
Well woman exam - One per plan year
$30 or $40
Vision, speech, and hearing screenings -For all enrolled participants
$40
Speech & hearing testing (covered for all participants)
$40
Speech therapy and rehabilitative therapy, including physical and occupational therapy-Covered as any other illness and not subject to any maximum
$40
Allergy testing
$40
Allergy serum
50%
Allergy serum administration-When allergy shot is administered without an office visit
No copayment
Routine eye exam-one per plan year
$40
Office surgery & procedures (all office surgeries, excluding vasectomies and tubal ligations)
$30 or $40
Maternity care - Physician services, including diagnosis of pregnancy, pre- & post-natal care, and delivery (including delivery by C-section) - see "Hospital Services" for Inpatient charges
