Blue Choice. Hospital/$50, Physician's Office/Lesser of $50 or 20%; physician $40, facility $50. $35/trip $100/trip $50/trip $100/trip $100/trip

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1 HOSPITAL SERVICES Hospital Inpatient : Paid in full No cost No cost No cost No cost Hospital Outpatient Hospital $40 or $60 per visit, : $20 per visit Hospital/$50, Physician's Office/Lesser of $50 or 20%; physician $40, facility $50 Hospital/$40, Physician's office: PCP/$25, Specialist/ $40, facility $50 Hospital/$100, Physician's Office/$20, Facility/$100 Hospital/$100, Physician's Office/$20, Facility/$100 Ambulance No copayment if service is provided by admitting hospital. $35/trip $100/trip $50/trip $100/trip $100/trip Emergency Room $60 or $70/visit No copayment. $100/visit $75/visit $100/visit $100/visit Urgent Care $30 or $40 per outpatient visit $35/visit $25/visit $35/visit $35/visit Skilled Nursing Facility Authorization Required. No cost up to 365 benefit days. No cost: 45 days per admission up to a maximum of 360 lifetime limit No cost up to 45 days No cost up to 50 days No cost up to 45 days Hospice No cost; unlimited No cost; 210 days No cost; 210 days No cost; 210 days No cost; unlimited Page 1

2 E M P I R E P L A N Blue Cross (Hospital) United HealthCare (Medical) PHYSICIAN SERVICES Office Visit $25/visit; $5 PCP sick $25/visit; $10 PCP sick visits for children to ; no cost for well visits for children to age age 26, no cost annual child care 26, Well Child $0 exam or well child, no cost for well child visits Specialty Office Visit $40/visit $40/visit Annual Routine Physical No Cost No Cost No cost No Cost Allergy Testing / Treatment Contact carrier Contact carrier Contact carrier Contact carrier Chiropractic $40/visit $40/visit Family Planning $25/visit PCP, $40/visit specialist $25/visit PCP, $40/visit specialist Infertility Services $30 or $40 Outpatient ; no cost at designated Center of Excellence; $50,000 lifetime maximum Applicable physician/facility copayment $25/visit PCP, $40/visit specialist (physician's office), $100/visit (outpatient surgery center) Page 2

3 Contraceptive Drugs/ Devices No copayment for certain FDA approved medications and devices. Applicable prescription copay applies No cost No cost Applicable prescription copay applies WOMEN'S HEALTH CARE Pap Tests $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost No cost Mammograms $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost for routine visit No cost Pre/Post Natal $20 per visit No cost No cost $20/initial visit only No cost Bone Density Tests $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost No cost DIAGNOSTIC / THERAPEUTIC SERVICES X-Rays $30 or $40/outpatient visit $40/visit $25/visit Lab Tests $30 or $40/outpatient visit No cost No cost No cost $10/visit Page 3

4 Pathology No Cost No cost No cost No cost $10/visit EKG/EEG $30 or $40/outpatient visit No cost $25/visit Radiation / Chemo No Cost No cost Radiation $25/visit/Chemo $50 Radiation $40/visit; Chemotherapy $40/visit MENTAL HEALTH / SUBSTANCE ABUSE Inpatient Mental Health No cost; unlimited when medically necessary No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Mental Health ; unlimited when medically necessary $40/visit; unlimited $25/visit (individual or group); unlimited ; unlimited ; unlimited Page 4

5 Inpatient Drug / Alcohol Rehab No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Drug / Alcohol Rehab to approved program; unlimited when medically necessary $25/visit; unlimited $25/visit; unlimited ; unlimited ; unlimited PRESCRIPTION DRUGS Prescription Drugs *Note: 3-tier system (generic, preferred brandname drugs, and nonpreferred brand-name drugs) Mail order OR retail pharmacy, 30 day supply: $5, $25, or $45. Mail order or network pharmacy day supply: $10, $50, or $90. Pharmacy day supply: $5, $50, or $90. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name co-payment plus the difference in cost between the brand-name drug and its generic equivalent. 30 days retail: $10/$30/$ days mail order: $20/$60/$100. Open formulary. 30 days retail: $10/$30/$ days mail order: $25 generic/$75 brand/$125 nonformulary. Open formulary 30 days retail: $5/$30/$ days mail order: $12.50/$75/$ days retail: $5/$30/$ days mail order:$12.50/$75/$150 MISCELLANEOUS Centers of Excellence for Cancer and/or Transplant No cost at designated Centers of Excellence. Precertification required. N/A N/A N/A N/A Page 5

6 Diabetic Supplies No cost. Call HCAP for Diabetic Shoes $500 annual max $25/item; 30 day supply, Diabetic shoes 50% coinsurance $25 copayment per boxed item/31 day supply, Diabetic shoes 50% coinsurance $20/item, Diabetic shoes not covered $20/item, Diabetic shoes - one pair/year when medically necessary Home Health Care No cost. Call HCAP for Contact carrier Contact carrier Contact carrier, max 40 visits Durable Medical Equipment No cost. Call HCAP for 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Orthotics Paid in full/no copayment 50% coinsurance 50% coinsurance 20% coinsurance No cost Prosthetics Paid in full/no copayment 50% coinsurance 50% coinsurance 20% coinsurance No cost Rehabilitative Care (PT, OT, Speech) Inpatient: no cost; for PT following surgery or hospitalization Inpatient: no cost up to 60 days. Outpatient: $40/visit up to 30 visits combined for: PT, Speech and OT Inpatient: no cost, two month max; Outpatient: $40/visit up to 30 visits Inpatient: no cost up to 45 days. Outpatient: ; max 20 visits. Inpatient: No cost up to 45 days. Outpatient: up to 20 visits per year Page 6

7 Alternative Medicine: Nutrition, Acupuncture, Massage Therapy Discount for network provider Contact carrier - Discounts available Each policy receives $100 to spend on health, wellness, and fitness programs. Contact for additional programs. $300 Wellness card allowance for use at Contact for additional programs. $275 Wellness card allowance for use at Contact for additional programs. Dental (preventive) Not covered $40/when associated with disease or injury $25/visit for children up to 19 Preventive: 20% discount at select providers; free second annual exam $50/cleaning; 20% discount on additional services at select providers Hearing Aids Non participating provider: up to $1500 per aid per ear every 4 years (every 2 years for children). Covered in full every three years for children Not covered to age 19. Discounts Available at select providers Discounts Available at select providers Vision (routine) Not covered $40/exam associated with disease or injury. $25/exam every 24 months VisionPlus Program $10/visit once/year. Page 7

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