Orally administered Refer to the Covered Services Refer to the Covered Services cancer prescription drugs and Supplies and Covered and Supplies and Covered Charges sections Charges sections All other Prescription Drugs Deductible/Coinsurance Deductible/Coinsurance SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (Continued) SERVICES [NETWORK] [NON-NETWORK] Home Health Care Covered; [$30] Copayment Deductible/Coinsurance; Subject to Pre-Approval Hospice Care Covered; $0 Copayment Deductible/Coinsurance; Subject to Pre-Approval SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (using separate deductible/coinsurance and maximum out of pocket for network and non-network services) [Note to carriers: Dollar amounts shown on the schedule pages are illustrative only. Refer to N.J.A.C. 11:21-3.1 for permissible ranges. Network benefits may be structured with tiers. For an example refer to the HMO contract form, Appendix Exhibit G.] THE SERVICES, SUPPLIES AND BENEFITS COVERED UNDER THIS CONTRACT ARE SUBJECT TO THE PAYMENT OF THE APPLICABLE COPAYMENTS, DEDUCTIBLE AND COINSURANCE. SERVICES [NETWORK] [NON-NETWORK] Primary Care Physician Visits [$15] Copayment / visit Deductible/Coinsurance Pre-Natal Care No Copayment, Deductible or Deductible/Coinsurance Coinsurance [Urgent Care [$30] Copayment / visit Deductible/Coinsurance] Emergency Room [$50] Copayment / visit; [$50] Copayment; waived if credited toward Inpatient admission occurs within 24 Copayment if admission hours; Deductible/Coinsurance occurs within 24 hours Immunizations and lead No Copayment, Deductible or Coinsurance screening for children Coinsurance Preventive Care No Copayment, Deductible or No Deductible or Coinsurance Coinsurance Orally administered Refer to the Covered Services Refer to the Covered Services
Orally administered prescription drugs Refer to the Covered Services and Supplies and Covered Charges sections Refer to the Covered Services and Supplies and Covered Charges sections All other Prescription Drugs Deductible/Coinsurance Deductible/Coinsurance SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (Continued) SERVICES [NETWORK] [NON-NETWORK] Home Health Care Covered; [$30] Copayment Deductible/Coinsurance; Subject to Pre-Approval Hospice Care Covered; $0 Copayment Deductible/Coinsurance; Subject to Pre-Approval SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (using separate deductible/coinsurance and maximum out of pocket for network and non-network services) [Note to carriers: Dollar amounts shown on the schedule pages are illustrative only. Refer to N.J.A.C. 11:21-3.1 for permissible ranges. Network benefits may be structured with tiers. For an example refer to the HMO contract form, Appendix Exhibit G.] THE SERVICES, SUPPLIES AND BENEFITS COVERED UNDER THIS CONTRACT ARE SUBJECT TO THE PAYMENT OF THE APPLICABLE COPAYMENTS, DEDUCTIBLE AND COINSURANCE. SERVICES [NETWORK] [NON-NETWORK] Primary Care Physician Visits [$15] Copayment / visit Deductible/Coinsurance Pre-Natal Care No Copayment, Deductible or Coinsurance Deductible/Coinsurance [Urgent Care [$30] Copayment / visit Deductible/Coinsurance] Emergency Room [$50] Copayment / visit; credited toward Inpatient Copayment if admission occurs within 24 hours [$50] Copayment; waived if admission occurs within 24 hours; Deductible/Coinsurance Immunizations and lead screening for children No Copayment, Deductible or Coinsurance Coinsurance Preventive Care No Copayment, Deductible or Coinsurance No Deductible or Coinsurance Orally administered Refer to the Covered Services Refer to the Covered Services cancer