difference between their charge and the allowed amount. - 10- Schedule of Medical Benefits 2016 2017 In-Network Out-of-Network Medical Plan Services Copay/Coinsurance Coinsurance Maternity Services Hospital Charges 25% 35% 25% (waived if enrolled in WellBaby 35% Physician Charges Program within first (delivery & inpatient) trimester) $25 (waived if enrolled in Prenatal Offices Visits 35% WellBaby Program within first trimester) Preventive Services Preventive screenings/ limited to services immunizations/flu shots listed on page 13 (adult & child Wellcare) & 14. Other Refer to pages 13 & 14 for listing of preventive services 35% Preventive Services covered at 100% subject to allowable and for age deductible and recommendations Mental Health Services Inpatient Services (Pre-certification is strongly 25% 35% recommended) First 4 visits $0 copay then $25 copay/visit Outpatient Services 35% Note: Psychiatrist is $40 copay/visit Chemical Dependency Inpatient Services (Pre-certification is strongly 25% 35% recommended)
difference between their charge and the allowed amount. - 10- Schedule of Medical Benefits 2016 2017 Medical Plan Services In-Network Copay/Coinsurance Out-of-Network Coinsurance Maternity Services Hospital Charges 25% 35% Physician Charges (delivery & inpatient) 25% (waived if enrolled in WellBaby Program within first trimester) 35% Prenatal Offices Visits $25 (waived if enrolled in WellBaby Program within first trimester) 35% Preventive Services Preventive screenings/ immunizations/flu shots (adult & child Wellcare) Refer to pages 13 & 14 for listing of Preventive Services covered at 100% allowable and for age recommendations limited to services listed on page 13 & 14. Other preventive services subject to deductible and 35% Mental Health Services Inpatient Services (Pre-certification is strongly recommended) 25% 35% Outpatient Services First 4 visits $0 copay then $25 copay/visit Note: Psychiatrist is $40 copay/visit 35% Chemical Dependency Inpatient Services (Pre-certification is strongly recommended) 25% 35%
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