Non-specialist office visits Specialist office visit $35(2,3,6) Co-pay per $45(1,2,3,6) Co-pay per 40%(5,6) Coinsurance visit visit HOSPITAL SERVICES – Inpatient (6,7) 10%(3,4,6,7) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance Coverage includes: Room and board Newborn delivery and other hospital obstetrical services In-hospital Provider/Practitioner visits, Surgeons, Anesthesiologist and other Inpatient services Detoxification Administration of blood/blood components MEDICAL SERVICES – Outpatient Surgeries(1)(7) Hospital/ASC Facility Fees 10%(3,4,6) 30%(1,2,3) 40%(5,6) Coinsurance Coinsurance Coinsurance Professional Fees 40%(5,6) Coinsurance 10%(3,4,6) 30%(1,3,4,6) Coinsurance Coinsurance X-ray, laboratory, and diagnostic tests Preventive No Co-pay(2) No Co-pay(1,2) Not Covered Non-preventive No Co-pay(2) No Co-pay(1,2) 40%(5) Coinsurance Endoscopy (6) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance Colonoscopy(Non-preventive or Preventive) 40%(5) Coinsurance No Co-pay(2) No Co-pay(1,2)
Non-specialist office visits Specialist office visit $35(2,3,6) Co-pay per visit $45(1,2,3,6) Co-pay per visit 40%(5,6) Coinsurance HOSPITAL SERVICES – Inpatient (6,7) Coverage includes: Room and board Newborn delivery and other hospital obstetrical services In-hospital Provider/Practitioner visits, Surgeons, Anesthesiologist and other Inpatient services Detoxification Administration of blood/blood components 10%(3,4,6,7) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance MEDICAL SERVICES – Outpatient Surgeries(1)(7) Hospital/ASC Facility Fees Professional Fees 10%(3,4,6) Coinsurance 10%(3,4,6) Coinsurance 30%(1,2,3) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance 40%(5,6) Coinsurance X-ray, laboratory, and diagnostic tests Preventive Non-preventive No Co-pay(2) No Co-pay(2) No Co-pay(1,2) No Co-pay(1,2) Not Covered 40%(5) Coinsurance Endoscopy (6) Colonoscopy(Non-preventive or Preventive) 10%(3,4,6) Coinsurance No Co-pay(2) 30%(1,3,4,6) Coinsurance No Co-pay(1,2) 40%(5,6) Coinsurance 40%(5) Coinsurance
Provider-Resource-Guide-2017-2018.docx