Preventive Care (Coverage under preventive care category depends on age, symptoms, and diagnosis)
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Routine Pap smears, mammograms, PSA, screening colonoscopy, and sigmoidoscopy
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$0
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Routine child care and immunizations (through age 18)
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$0
|
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Routine adult physical exam (19 years and above, one per plan year)
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$0
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Physician Services
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Primary care office visits (excludes certain diagnostic lab and X-ray)
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$10 co-payment for primary care physician
|
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Specialist office visits (excludes certain diagnostic lab and X-ray)
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$30 co-payment for specialist
|
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Lab tests, X-rays and diagnostic tests
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$0
|
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Allergy injections
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$10 co-payment
|
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Inpatient services
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$0
|
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Outpatient surgery and diagnostics
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$0
|
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Physician visits to emergency room
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$0
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Hospital Services
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Inpatient care (semi-private room and board, nursing care, ICU)
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$200 co-payment per admission
|
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Hospital observation stay
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$100 co-payment
|
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Organ transplants
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$0
|
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Outpatient nonsurgical care
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$0
|
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Outpatient tests, lab, X-ray and other diagnostic tests
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$0
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Ancillary services
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$0
|
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Outpatient surgery
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$75 co-payment
|
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Outpatient diagnostic testing (high costs - MRI, MRA, CT and PET scans)
|
$75 co-payment
|
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Emergent/Urgent Services
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Emergency room
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$100 co-payment, then 10% co-insurance (waived if admitted)
|
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Urgent treatment center
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$25 co-payment
|
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UK Children's Twilight Clinic
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$15 co-payment
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Ambulance
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$75 co-payment
|
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Other Medical Services
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Skilled nursing facility (up to 30 per plan year) and hospice services
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$0
|
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Home health care (up to 60 visits per plan year)
|
20% co-insurance
|
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Durable medical equipment, orthotics, and prosthetics
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20% co-insurance up to $500 member cost per year
|
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Hearing aids
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20% co-insurance for children under 18
|
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Speech, music, physical, occupational, manipulative, hydrotherapy, acupuncture, pulmonary rehab, and cardiac rehab therapy (limited to 45 visits per plan year, combined)
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$15 co-payment per visit for all therapies
|
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Mental Health and Substance Abuse
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Inpatient mental health or substance abuse
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$200 co-pay per admission
|
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