[Telemedicine Visits [$15] Copayment / visit N/A] [$15] Copayment / visit N/A] [E-Visits [$15] Copayment / visit N/A] [Virtual Visits Preventive Care; [$0] Copayment / visit [Deductible/Coinsurance] Surgery Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Pre-Admission Testing [$15] Copayment Deductible/Coinsurance Second Surgical Opinion [$15] Copayment Deductible/Coinsurance SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (Continued) SERVICES [NETWORK] [NON-NETWORK] Specialist Services [$15] Copayment Deductible/Coinsurance Therapy Services NOTE: [$15] Copayment Deductible/Coinsurance Limited Benefits. Refer to the Covered Services and Supplies and Covered Charges sections [Complex Imaging Services [$30 Copayment] Deductible/Coinsurance] [All other] Diagnostic Services Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Rehabilitation Services Subject to the Hospital Deductible/Coinsurance NOTE: [Non-Network] Inpatient Copayment; waived benefits LIMITED. Refer to if admission immediately the Covered Charges section preceded by inpatient hospitalization Center NOTE: $0 Copayment Deductible/Coinsurance benefits LIMITED. Refer to the Covered Charges section
[Telemedicine Visits [E-Visits [Virtual Visits [$15] Copayment / visit [$15] Copayment / visit [$15] Copayment / visit N/A] N/A] N/A] Preventive Care; [$0] Copayment / visit [Deductible/Coinsurance] Surgery Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Pre-Admission Testing [$15] Copayment Deductible/Coinsurance Second Surgical Opinion [$15] Copayment Deductible/Coinsurance SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (Continued) SERVICES [NETWORK] [NON-NETWORK] Specialist Services [$15] Copayment Deductible/Coinsurance Therapy Services NOTE: Limited Benefits. Refer to the Covered Services and Supplies and Covered Charges sections [$15] Copayment Deductible/Coinsurance [Complex Imaging Services [$30 Copayment] Deductible/Coinsurance] [All other] Diagnostic Services Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Rehabilitation Services NOTE: [Non-Network] benefits LIMITED. Refer to the Covered Charges section Subject to the Hospital Inpatient Copayment; waived if admission immediately preceded by inpatient hospitalization Deductible/Coinsurance Center NOTE: benefits LIMITED. Refer to the Covered Charges section $0 Copayment Deductible/Coinsurance
hmopos_contract.docx