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 preventive screenings

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance (PA) for covered tests*

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 immunizations

Subject to the calendar year deductible (Individual or Family)

35% of Plan allowance*

Note: Your deductible and coinsurance amount are waived for Influenza vaccines billed by Participating and Non-participating providers

• Well Child Care up to age 22, including preventive services recommended under the Patient Protection and Affordable Care Act. These services include but are not limited to routine physical examinations, routine hearing and vision screenings, laboratory tests, immunizations, and related office visits, and nutrition counseling.

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of Plan allowance*

• Inpatient services, including surgical and medical care

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

• Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests, pathology services, urinalysis and diagnostic tests

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

• Home and office visits, second surgical opinions, outpatient consultations and medical emergency care

$20 office visit copayment for primary care provider

$30 office visit copayment for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

• Outpatient physical, occupational and speech therapy benefits are limited to 75 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three  

$20 copayment per visit for primary care provider

$30 copayment per visit for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

• Physician care, including delivery and pre-and post-natal and and postpartum care

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

• Inpatient hospital and physician care

Precertification is not required

Nothing for covered charges

35% of the Plan allowance*

Prescription Drugs Mail Service Pharmacy

You pay nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Up to a 90-day supply when you use Preferred Pharmacies or Internet Pharmacies. Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Tier 1: $15 copayment for generic drugs. If you have Medicare Part B as your primary coverage, you pay a $10 copayment. 
Tier 2: $70 each for the first 30 Preferred brand-name drug prescriptions fills or refills, $50 copayment thereafter.
Tier 3: $95 each for the first 30 non-Preferred brand-name drug prescriptions, $50 copayment thereafter
Formulary
Prior Authorization

There is no benefit

Prescription Drugs Retail Pharmacy

Up to a 90-day supply when you use Preferred Pharmacies or Internet Pharmacies. Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Tier 1: 20% PPA for generic drugs. If Medicare Part B is your primary payer, you pay 15% PPA.
Tier 2: 30% PPA for Preferred brand-name drugs.
Tier 3: 45% PPA for non-Preferred brand-name drugs.
Tier 4: If you purchase specialty drugs at a retail pharmacy, you pay 30% the Preferred Plan Allowance.
Formulary
Prior Authorization

45% of Plan allowance, plus any difference between our allowance and the billed amount.

Specialty Prescription Drugs Pharmacy 

Tier 4: $80 copayment for specialty drugs purchased through our Specialty Drug Pharmacy Program.

• Hospital inpatient room and board and other inpatient hospital services 

Precertification required

Unlimited days

$250 per admission copayment

Unlimited days

$350 per admission copayment

35% of the Plan Allowance*

• Hospital/Facility care – outpatient surgery

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Hospital/Facility care - outpatient services including medical emergency care, diagnostic tests, renal dialysis, radiation therapy, and chemotherapy.

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Outpatient physical, occupational and speech therapy (when performed and billed by a hospital or freestanding ambulatory facility). Benefits are limited to 75 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three.

$20 visit copayment

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Covered charges in connection with and within 72 hours after an accidental injury at a facility or in a physician's office.

NOTE: For services received after 72 hours, regular medical and outpatient hospital benefits apply.

Nothing for covered services

Nothing for covered services. You may be responsible for any difference between the Plan Allowance and the billed amount.

• 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.

Preferred: $20 copayment per visit (No deductible)

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Note: Office visits and X-rays that you pay for while meeting your calendar year deductible count toward the appropriate benefit limit.

Manipulative treatment performed by a Doctor of Osteopathy (D.O.), Doctor of Medicine (M.D.), or Doctor of Chiropractic (D.C.) when the provider is practicing within the scope of his/her license, limited to:

• Osteopathic manipulative treatment of any body region
• Chiropractic spinal and/or extra-spinal manipulative treatment

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.

Preferred: $20 copayment per visit (No deductible)

Note: Benefits are limited to 12 manipulations per calendar year.

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Note: Manipulations that you pay for while meeting your calendar year deductible count toward the appropriate benefit limit.

Note: Benefits are limited to 12 manipulations per calendar year.

• Inpatient Hospital

Precertification required

$250 per admission copayment

Unlimited days

Unlimited days, $350 per admission copayment, plus 35% of the Plan Allowance*

• Outpatient Facility Care

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Inpatient Professional Care

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Outpatient Professional Care

$20 office visit copayment for primary care provider

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

• Catastrophic protection (Please refer to Section 4 in the Service Benefit Plan brochure  (R 71-005) for charges applied to this benefit.)

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

100% payment level begins after you pay $7000 out-of-pocket in coinsurance, copayment and deductible expenses