| Primary and specialty care visits |
$30.00 per visit after deductible is met (Includes routine and urgent care appointments) |
| Well child visits-0-23 months |
$10.00 per office visit |
| Family planning visits |
$30.00 per office visit after deductible is met |
| Scheduled prenatal care |
$10.00 per visit |
| First postpartum visit |
$10.00 per visit is met after deductible is met |
| Eye examinations |
$30.00 per office visit after deductible is met |
| Hearing test |
$30.00 per office visit after deductible is met |
| Chiropractic |
not covered |
| Physical, speech, occupational |
$30.00 per office visit after deductible is met |
| Inpatient psychiatry |
30% coinsurance per admission after deductible is met |
| Outpatient visits individual |
$30.00 per visits up to 20 per calendar year |
| Group therapy |
$15.00 per visit up to 20 per calendar year. Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year |
| Inpatient chemical dependency detoxification |
30% coinsurance per admission after deductible |
| Outpatient individual therapy |
$30.00 per visit after deductible is met |
| Outpatient group therapy visits |
$5.00 per visit after deductible is met |
| Transitional residential recovery services |
$100.00 per admission after deductible is met (Up to 60 days per calendar year, not to exceed 120 days in any five-year period) |
