Page 37 - 2021-2022 New Hire Benefits

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 $75 copayment/service
MRI, PET and CAT scan and after plan deductible
nuclear cardiology
up to ve copayments per year

Advanced radiology
Stand-alone facility $75 copayment/service
MRI, PET and CAT scan and after plan deductible
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 after plan deductible

Emergency room $150 copayment/visit
copayment waived if admitted after plan deductible

CCI/HMO OA HDHP/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129628
CT H00155571 / MA H01255572 -129628
Choice HMO-OA-CNT-HSA-3000I/6000F-30-45-05
Bene t ID: bI