| Benefit Description |
Member Copayments FY2005 |
|
Physicians and Lab Services
|
|
| Physician Office Visit - Primary Care Physician (PCP) |
$30 Copay |
| Specialist Office Visit |
$40 Copay |
Routine physicals - One per plan year for adults; periodic for children, or as directed by the Primary Care Physician
|
$30 to the PCP or $40 to
the specialists |
| Diagnostic x-rays, mammography, and lab test |
No Copayment |
Immunizations - For children 0 to 6 years of age
|
No Copayment |
Immunizations - For children 7 years and older, and adults
|
$30 Copay |
Well Woman exam - One per plan year
|
$30 to the PCP or $40 to
the specialists |
Vision, speech, and hearing screenings
For all enrolled Participants
|
$40 Copay |
Speech and hearing testing (covered for all Participants)
|
$40 Copay
|
Speech theraphy and rehabilitative therapy, including physical and occupational therapy.
Covered as any other illness and not subject to any maximum
|
$40 Copay
|
| Allergy testing |
$40 Copay |
| Allergy serum |
50% of the Allowable Amount |
Allergy serum administration
When allergy shot is administered without an office visit. |
None |
| Routine eye exam - One per plan year |
$40 Copay |
Office surgery and diagnostic procedures
(all office surgeries, excluding vasectomies and tubal ligations) |
$30 to the PCP or $40 to
the specialist |
| Outpatient surgery when preformed in a facility other than a doctor's office. |
$100 Copay |
Maternity care
Hospital and Physician services, including diagnosis of pregnancy, pre and post-natal care, and delivery (including delivery by C-section) |
No Copayment for physician services; applicable Copayments apply for Hospital services |
| Family Planning |
$40 Copay |
| Vasectomy and tubal ligation |
No Copayment for procedures performed in the Physician's office. Otherwise, all applicable Copayments will apply, dependent upon place of service. |
| Infertility benefits |
50% of the Allowable Amount |
