Preventive care services for adults age 22 and older including the preventive services recommended under the Patient Protection and Affordable Care Act. Services include but are not limited to:

• Routine physical exams, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC, fasting lipid profile, cholesterol tests and metabolic and general health panel tests annually
• Preventive screenings: Pap smears, mammograms, stool tests for blood, prostate specific antigen tests, sigmoidoscopies, STD screenings, genetic counseling in certain situations, and related office visits

• Nothing for covered charges

Routine immunizations for adults age 22 and older [as licensed by the U.S. Food and Drug Administration (FDA)], limited to:

• Hepatitis (Types A and B) for patients with increased risk or family history
• Herpes Zoster (shingles)*
• Human Papillomavirus (HPV)*
• Influenza (flu)*
• Measles, Mumps, Rubella
• Meningococcal*
• Pneumococcal* 
• Tetanus-diphtheria, pertussis booster (one every 10 years)
• Varicella

*Many Preferred retail pharmacies participate in our vaccine network.  Review pharmacy benefits for our coverage of these vaccines when provided by pharmacies in the vaccine network.

• Nothing for covered charges

• Surgical care

• $150 copayment per performing surgeon

• Office visits, home visits, second surgical opinions and consultations 

• $25 office visit copayment for primary care provider
• $35 office visit copayment for specialists
• You pay 30% PPA for drugs and supplies

• Inpatient hospital and physician care

Precertification is not required

• Nothing for professional charges for prenatal and postnatal care and delivery
• $150 per admission copayment

• Mail Service Pharmacy  

Not offered

• Retail Pharmacy

• Tier 1 (generic): $10 copayment for a 34-day supply or $30 for a 90-day supply.
• Tier 2 (Preferred brand-name): $40 copayment for a 34-day supply or $120 for a 90-day supply.
• Tier 3 (Non-Preferred brand-name): 50% PPA ($50 minimum) for a 34-day supply or 50% PPA ($150 minimum) for a 90-day supply.
• Tier 4 (Specialty drug): $50 copayment for a 34-day supply or $150 for a 90-day supply for specialty drugs purchased at a Preferred retail pharmacy.

• Specialty Pharmacy

• Tier 4 (Specialty drug): $40 copayment for a 34-day supply or $120 for a 90-day supply. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.

• Inpatient Hospital - Precertification is required

• $150 copayment per day up to $750 per admission for unlimited days

• Outpatient facility care, excluding laboratory, EEG, ultrasounds, and x-ray services

• $100 per day per facility copayment

• Outpatient facility care: EEG, ultrasounds, x-ray services

• $25 copayment

• Outpatient facility care, laboratory

• Nothing for covered charges

• Outpatient facility care for surgical services 

• $100 per day per facility copayment

• Outpatient facility care for drugs, medical devices, and durable medical equipment

• 30% Preferred Plan Allowance (PPA)

• Accidental injury or medical emergency - emergency room

• $125 copayment

• Accidental injury or medical emergency - urgent care

• $50 copayment

• Accidental injury and medical emergency - physician care  

• $25 for preferred primary care provider office visit
• $35 copayment for preferred specialist office visit

• One office visit per calendar year
• One set of X-rays per calendar year

Note: Benefits may be available for other covered services you receive from chiropractors in medically underserved areas. See page 12 in the Service Benefit Plan brochure (R 71-005) for additional information.

• $25 copayment per visit

Catastrophic Services  

100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses