Medical Plan Services
In-Network Copay/Coinsurance
Out-of-Network Coinsurance
Complementary Health Care Services Acupuncture
Naturopathic
Members pay charges over $25/visit
Members pay charges over $25/visit
Max: 15 visits/yr in combination with Naturopathic
Max: 15 visits/yr in combination with Naturopathic
Members pay charges over $25/visit
Members pay charges over $25/visit
Max: 15 visits/yr in combination with Acupuncture
Max: 15 visits/yr in combination with Acupuncture
$15/visit Max: 20 visits/yr
Max: 20 visits/yr
$15 copay/visit Max: 30 visits/yr
35% Max: 30 visits/yr
25% Max: 6 months
35% Max: 6 months
25% Max: 30 days/yr
35% Max: 30 days/yr
$15 copay/visit
35%
Chiropractic
35%
Extended Care Services Home Health Care (Prior authorization is strongly recommended)
Hospice
Skilled Nursing (Prior authorization is strongly recommended)
Miscellaneous Services Allergy Shots Durable Medical Equipment, Prosthetic Appliances & Orthotics (Prior authorization is required for amounts greater than $2,500)
25%
Max: $200 for foot orthotics
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35%
Max: $200 for foot orthotics