Page 25 - 2021-2022 New Hire Benefits
P. 25

Screenings                            In-network member pays

        Allergy testing
        Unlimited                             Refer to your applicable primary care or specialist cost share

        Ongoing Care and Sick Visits          In-network member pays
                                              $30 copayment/visit
        Primary care services
                                              after plan deductible
                                              $45 copayment/visit
        Specialist services
                                              after plan deductible
                                              $30 copayment/visit
        Gynecologist services
                                              after plan deductible
        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
                                              $30 copayment/visit
        Retail clinic
                                              after plan deductible
        Lab and Radiology
        Performed in a hospital, lab or       In-network member pays
        radiology facility

                                              0% coinsurance
        Laboratory services
                                              after plan deductible
        Non-advanced radiology                0% coinsurance
        X-ray, diagnostic                     after plan deductible
        Advanced radiology
        Hospital facility                     0% coinsurance
        MRI, PET and CAT scan and             after plan deductible
        nuclear cardiology
        Advanced radiology
        Stand-alone facility                  0% coinsurance
        MRI, PET and CAT scan and             after plan deductible
        nuclear cardiology
        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          0% coinsurance
        clinic                                after plan deductible

                                              0% coinsurance
        Emergency room
                                              after plan deductible





       CCI/HMO OA HDHP/BS LG (01/2021) E ective Date: 7/2021
       Choice_HMO-OA-129629
       CT H00153596/H00153595 / MA H01253593/H01253594 -129629
       Choice HMO-OA-CNT-HSA-2000I/4000F-30-45-04
       Bene t ID: lp/LR
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