Generic Copayment $10 Brand Copayment $15 – – Laboratory and Pathology Tests(4) None Maternity/OB-GYN/Family Services(3) Artificial Insemination $5 Copayment per trial Elective Abortions Professional Service $5 Copayment Outpatient Facility Services Maternity/Obstetrical Care Professional Service Single Copayment of $5 Facility Service Newborn Care None Medical Care(2) None Medical Foods and Nutritional Formulas(1) None BENEFIT COST-SHARING Mental Health Care(3)3 Inpatient Mental Health Care Admissions Outpatient Mental Health Care $5 Copayment per Visits/Sessions Inpatient Serious Mental Health Care Admissions Outpatient Serious Mental Health Care $5 Copayment per Visits/Sessions Nutrition Counseling For Weight Management(1) Note for Nutrition Counseling For Weight Management shown above: Benefit Period Maximum: 6 counseling visits/sessions. $5 Copayment per visit Preventive Care Adult(1) – Preventive Care Pediatric(1) $5 Copayment per visit – Primary Care Physician Office Visits/Retail $5 Copayment per visit Clinic - Non-Preventive(1) Primary Care Physician Office Visits $10 Copayment per – Non-Preventive(1) (Home Visits and after hour visits) Private Duty Nursing Services(4) None Prosthetic Devices(4) None Skilled Nursing Facility Services(2) None
Generic Copayment – $10 Brand Copayment – $15 Laboratory and Pathology Tests(4) Maternity/OB-GYN/Family Services(3) Artificial Insemination $5 Copayment per Elective Abortions Professional Service $5 Copayment Outpatient Facility Services Maternity/Obstetrical Care Professional Service Single Copayment of $5 Facility Service None Newborn Care Medical Care(2) Medical Foods and Nutritional Formulas(1) BENEFIT COST-SHARING Mental Health Care(3)3 Inpatient Mental Health Care Admissions None Outpatient Mental Health Care Visits/Sessions $5 Copayment per Inpatient Serious Mental Health Care Admissions None Outpatient Serious Mental Health Care Visits/Sessions $5 Copayment per Nutrition Counseling For Weight Management(1) None Note for Nutrition Counseling For Weight Management shown above: Benefit Period Maximum: 6 counseling visits/sessions. Preventive Care – Adult(1) $5 Copayment per visit Preventive Care – Pediatric(1) $5 Copayment per visit Primary Care Physician Office Visits/Retail Clinic - Non-Preventive(1) $5 Copayment per visit Primary Care Physician Office Visits – Non-Preventive(1) (Home Visits and after hour visits) $10 Copayment per Private Duty Nursing Services(4) None Prosthetic Devices(4) None Skilled Nursing Facility Services(2) None trial
ST-7.docx