| Emergency and Urgent Services |
| Accident |
$40 |
$40 |
| Illness |
$100 |
$100 |
| Urgent Care Services |
| Urgent Care Center |
$15 |
$15 |
| Hospitalization due to accident |
| Hospitalization (including mental health) Level I (PPO) |
$50 |
$50 |
| Hospitalization (including mental health) Level 2 (PPO) |
$550 |
$600 |
| Hospitalization |
| Hospitalization (including mental health) Level I (PPO) |
$200 |
$200 |
| Hospitalization (including mental health) Level 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 |
30% |
30% |
| 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% |
