Page 13 - 2021-2022 New Hire Benefits

Ongoing Care and Sick Visits In-network member pays

Maternity and prenatal care
visits
May not apply to all laboratory and No charge
radiology services – refer to your
plan documents
Allergy injections Refer to your applicable primary care or specialist cost share
Unlimited

Telemedicine visit Refer to your applicable primary care or specialist cost share
Retail clinic $30 copayment/visit

Lab and Radiology
Performed in a hospital, lab or In-network member pays
radiology facility
Laboratory services No charge

Non-advanced radiology $10 copayment/visit
X-ray, diagnostic

Advanced radiology
Hospital facility
MRI, PET and CAT scan and $75 copayment/service
nuclear cardiology
up to ve copayments per year

Advanced radiology
Stand-alone facility
MRI, PET and CAT scan and $75 copayment/service
nuclear cardiology
up to ve copayments per year
Sudden and Unexpected Care
The same cost share applies for In-network member pays
both in-network and out-of-
network service

Urgent care or other walk-in $75 copayment/visit
clinic

Emergency room $300 copayment/visit
copayment waived if admitted
Ambulance No charge

Inpatient Hospital Services In-network member pays

Inpatient hospital services, $500 copayment/day up to $2,000 per year
including room and board

Skilled nursing and
rehabilitation facilities $500 copayment/day up to $2,000 per year
up to 90 days per year

Outpatient Hospital Services
and Home Care In-network member pays

Hospital outpatient facilities $300 copayment/visit

CCI/HMO/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129630
CT H00154139 / MA H01254140 -129630
Choice HMO-OA-CNT-30-45-300-500D-01
Bene t ID: Lk