WOMEN’S HEALTH CARE Preventive Care Services No Co-pay(2,8) No Co-pay(1,2,8) 40%(5) Coinsurance Well-woman visits to include adult and female-specific screenings Mammograms Cytological Screening (Pap tests) including screening for papillomavirus Screening for gestational diabetes Counseling for HIV and sexually transmitted diseases Screening and counseling for interpersonal and domestic violence FDA Approved Surgical sterilization procedures for women’s sterilization Contraceptive implant insertion/re- insertion fee Contraception counseling Breast feeding support, supplies and counseling(8) Non-preventive Non-specialist $25(2,3) Co-pay per $30(1,2,3) Co-pay per 40%(5) Coinsurance visit visit Specialist (includes Perinatologist) $35(2,3) Co-pay per $45(1,2,3) Co-pay per 40%(5) Coinsurance visit visit Obstetrical/Maternity/Prenatal and Postnatal $25(2, 3) Co-pay for $30(1,2,3) Co-pay for 40%(5) Coinsurance care (excludes delivery) first visit. (Plan pays first visit. (Plan pays 100% thereafter) 100% thereafter) DIABETES SERVICES Office visit and Diabetes Education Non-specialist $25(2,3) Co-pay per $30(1,2,3) Co-pay per 40%(5) Coinsurance visit visit
WOMEN’S HEALTH CARE Preventive Care Services Well-woman visits to include adult and female-specific screenings Mammograms Cytological Screening (Pap tests) including screening for papillomavirus Screening for gestational diabetes Counseling for HIV and sexually transmitted diseases Screening and counseling for interpersonal and domestic violence FDA Approved Surgical sterilization procedures for women’s sterilization Contraceptive implant insertion/re- insertion fee Contraception counseling Breast feeding support, supplies and counseling(8) No Co-pay(2,8) No Co-pay(1,2,8) 40%(5) Coinsurance Non-preventive Non-specialist $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(5) Coinsurance Specialist (includes Perinatologist) $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Obstetrical/Maternity/Prenatal and Postnatal care (excludes delivery) $25(2, 3) Co-pay for first visit. (Plan pays 100% thereafter) $30(1,2,3) Co-pay for first visit. (Plan pays 100% thereafter) 40%(5) Coinsurance DIABETES SERVICES Office visit and Diabetes Education Non-specialist $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(5) Coinsurance
Provider-Resource-Guide-2017-2018.docx