Copays & Visits
What's the copay for a PCP, Specialist, or Urgent Care visit?
$50
What's the copay for outpatient surgery?
$250 after deductible
What's the copay for outpatient mental health visits?
$50 after deductible
What's the copay for preventative generics?
$0 before the deductible
Is maternity covered?
Yes, but with a 12 month waiting period
How many combined visits are allowed per year for PCP, specialist, and urgent care?
10 visits per benefit year combined
How many inpatient surgeries are covered per year?
2 inpatient surgeries per benefit year
How many outpatient mental health visits are allowed per year?
15 days per benefit year
What is the copay for DME's?
$50 per item received
What is the maternity copay for a vaginal vs C-section delivery?
$250 for vaginal; $500 for C-section after deductible
What's the copay for basic lab tests (3 per year)?
$25
What's the copay for inpatient hospitalization?
$1,000 copay after deductible
What's the inpatient mental health copay?
$250 after deductible
What does Med Defender Pro do?
It negotiates unexpected medical bills
Is Durable Medical Equipment (DME) covered, and what's the max items you can receive?
Yes, max 5 items per benefit year
How many chiropractic visits are allowed per year? What's the copay?
12 visits max; $50 copay
What are the stay limits for inpatient hospital admissions?
Max 2 hospitalizations/year; 10-day limit per stay
What other therapies are covered?
Physical & Occupational Therapy - Speech Therapy - Cardiac Rehabilitation Therapu
What is the limit for Home health care and what is the copay?
10-day limit per benefit year; $50 copay
Are elective surgeries included?
No, they are not covered.
what is the copay for advanced imaging (e.g. MRI) and what is needed before it is covered?
$200 copay; Prior authorization is required before
How many outpatient surgeries are covered in a benefit year, and what is not covered?
3 surgeries per benefit year; Elective surgeries not covered
How many visits are allowed for therapies like Physical, Speech and Cardiac Rehab?
16 visits per benefit year max combined
How many allergy visits and shots are allowed per year, and what are the copays?
2 allergy visits at $50 copay; 24 allergy shots at $25 each.
What is the copay for non-emergency transport?
Non-emergency Transport is NOT covered.