Outpatient Services

• Medical visits
• Generalists - $3
• Specialists - $12
• Subspecialists - $12
• Chiropractic - $5 (Maximum 25 treatments per policy year)
• Podiatrist - $12
• Respiratory Therapies - $5 copayment (Maximum 25 treatments per condition, per policy year)
• Physical Therapy - $5 (Maximum 25 treatments per condition, per policy year)

Specialized procedures

• Laboratories - 25% coinsurance
• X-rays - 20% coinsurance
• Magnetic resonance imaging (MRI, MRA) - 20% coinsurance (First does not require pre-authorization, excess of (1) requires authorization)
• CT Scan - 20% coinsurance (First does not require pre-authorization, excess (1) requires authorization)
• Sonograms - 20% coinsurance
• Polysomnography - 20% coinsurance
• Endoscopy - 20% coinsurance

Dental Services

• Diagnostic and preventive - 0%
• Minor and major restorative - 20%
• Endodontics - 20%
• Periodontics - 20%
• Endodontics - 20%
• Prostheses - 20%

Vision Services

• $0 copayment for refractive examination
• $15 copayment for optometrical visit
• $150 maximum benefit for glasses or contact lenses every 12 months

Pharmacy Coverage

Bioequivalent

• $0 copayment

Brand - Coinsurance

• $10 Brand Single Source
• $30 Brand Multi Source

Bioequivalent drugs are first choice, if you choose the brand-name drug you will pay the difference between the bioequivalent copayment and the brand-name drug cost.