| Emergency and Urgent Services |
| Accident | $40 | $40 |
| Illness | $100 | $100 |
| Urgent Care Services |
| Urgent Care Center | $20 | $20 |
| Hospitalization |
| Hospitalization (including mental health) Nivel I (PPO) | $200 | $200 |
| Hospitalization (including mental health) Nivel 2 (PPO) | $700 | $750 |
| Partial Hospitalization (PPO) | $100 | $100 |
| Skilled Nursing Facility | 30% | 30% |
| Surgical Assistance in Hospital | 50% | 50% |
| Ambulatory Services |
| General Practitioner, Psychiatrist, Psychologist, Family Physicians and Nutritionists (VIP) | $0 | $0 |
| General Practitioner, Psychiatrist, Psychologist, Family Physicians and Nutritionists (PPO) | $0 | $0 |
| Specialist includes: Podiatrist, Chiropractor (first visit), Audiologist and Optometrist (VIP) | $12 | $12 |
| Specialist includes: Podiatrist, Chiropractor (first visit), Audiologist and Optometrist (PPO) | $15 | $15 |
| Subspecialist (VIP) | $18 | $18 |
| Subspecialist (PPO) | $20 | $20 |
| Naturopathic Doctors | $15 | $15 |
| Ambulatory Facility | $150 | $150 |
| Diagnostic and medical procedures in Medical Office | 50% | 50% |
| Diagnostic and medical procedures in Ambulatory Facilities | 50% | 50% |
| Endoscopic procedures | 45% | 50% |
| Chemotherapy, radiotherapy and drugs for chemotherapy preparation | 25% | 25% |
| Dialysis and hemodialysis | 10% | 10% |
| Rehabilitation, Habilitation and Durable Medical Equipment |
| Physical Therapy (Includes: respiratory therapy and manipulations of chiropractors) | $10 | $10 |
| Home Health Care | 50% | 50% |
| Durable Medical Equipment (DME) | 50% | 50% |
| Mental Health |
| Group Therapy | $0 | $0 |
| Collateral Visits | $0 | $0 |
| Prescription Drugs (Pharmacy) |
| First level of coverage (amount to apply the first level’s copayments or coinsurances) | Up to $800 | N/A |
| Second Level Coverage (after having exhausted first level drugs) | 90% | N/A |
| Preferred Generic (First level) | $5 | $10 |
| Non-Preferred Generic (First level) | $15 | $10 |
| Preferred Brand (First level) | 50% min $25 | 89% |
| Non-Preferred Brand (First level) | 75% | 89% |
| Preferred Specialty Drugs (First level) | 75% | 89% |
| Non-Preferred Specialty Drugs (First level) | 75% | 89% |
| Over the Counter Drugs (OTC) – (First level) | $1 | $1 |
| Mail Order Program |
| Preferred Generic (First level) | $20 | $20 |
| Non-Preferred Generic (First level) | $20 | $20 |
| Preferred Brand (First level) | 50% min $50 | 89% |
| Non-Preferred Brand (First level) | 89% | 89% |
| Retail 90 day Drugs (Retail 90) |
| Preferred Generic (First level) | $30 | $30 |
| Non-Preferred Generic (First level) | $30 | $30 |
| Preferred Brand (First level) | 50% min $75 | 89% |
| Non-Preferred Brand (First level) | 89% | 89% |
| Laboratories and X Rays Services |
| Laboratory | 35% | 35% |
| X Rays (includes: nuclear medicine, cardiac diagnostic tests (stress test, echo cardio, and others) | 30% | 35% |
| Specialized Tests (CT Scan, PET Scan, PET CT, MRI, SPECT) | 45% | 45% |
| Molecular and/or Genetic tests | 75% | 75% |
| Preventive, Wellness and Chronic diseases management |
| Preventive Services (including women and Autism) | 0% | 0% |
| Preventive Immunizations (Vaccines) | 0% | 0% |
| Immunization (Vaccine) for Respiratory Syncytial Virus (RSV) | 0% | 0% |
| Pediatric Dental & Vision Services |
| Pediatric Dental | 0% | 0% |
| Pediatric Vision (Visual Correction Lenses or frames for Visual Correction) | 0% | 0% |
