URGENT CARE $75(2,3) Co-pay per $75(2,3) Co-pay per 40%(5,6) Coinsurance visit visit AMBULANCE SERVICES Includes: 30%(3,4) Coinsurance Emergency or high risk Ground and Air ambulance Applies to In-Network No Co-pay(2) Applies to In-Network Benefit Benefit Inter-facility transfer services Ground and Air ambulance CLINICAL PREVENTIVE SERVICES No Co-pay(2,8) No Co-pay(1,2,8) Not Covered Includes: Well child care including vision and hearing screening Preventive physical exam Adult and child immunizations Office based health education Family Planning Services Colonoscopy
URGENT CARE $75(2,3) Co-pay per visit $75(2,3) Co-pay per visit 40%(5,6) Coinsurance AMBULANCE SERVICES Includes: Emergency or high risk Ground and Air ambulance Inter-facility transfer services Ground and Air ambulance Applies to In-Network Benefit 30%(3,4) Coinsurance No Co-pay(2) Applies to In-Network Benefit CLINICAL PREVENTIVE SERVICES Includes: Well child care including vision and hearing screening Preventive physical exam Adult and child immunizations Office based health education Family Planning Services Colonoscopy No Co-pay(2,8) No Co-pay(1,2,8) Not Covered
Provider-Resource-Guide-2017-2018.docx