Commonwealth Care Type I
Click here to print.
| Covered Benefit | Co-Payment |
|---|---|
| Outpatient Medical Care | |
| Community Health Center Visits (Primary Care and Specialist) | $0 |
| Preventive Care Service (including Family Planning visits) | $0 |
| Office Visits (PCP/Specialists) | $0 |
| Outpatient Surgery (Hospital and Ambulatory Surgery Centers) | $0 |
| Abortion Services | $0 |
| X-rays/Labs | $0 |
| High Cost Imaging Services (MRI, CAT, PET) | $0 |
| Inpatient Medical and Maternity Care (includes deliveries/surgery/x-rays/lab) | $0 |
| Prescription Drugs | |
| Medication via Pharmacy (1 month supply) *Applies to a limited list of prescription drugs only |
Generic* $1 Generic $3.65 Brand $3.65 |
| Contraceptives | $0 |
| Emergency Care | $0 |
| Inpatient Mental Health & Substance Abuse | $0 |
| Outpatient Mental Health & Substance Abuse | $0 |
| Methadone Treatment (dosing, counseling, labs) | $0 |
| Rehabilitation Services | |
| Cardiac Rehabilitation | $0 |
| Home Health Care | $0 |
| Inpatient Rehabilitation Services (combined 100 days per Contract Year) |
|
| Skilled Nursing Facility | $0 |
| Inpatient Rehabilitation or Chronic Disease Hospital | $0 |
| Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapies) Prior Authorization required for all services |
$0 |
| Other Benefits | |
| Ambulance (emergency or prior authorized ambulance transport only) | $0 |
| Dental (emergency and preventative only) | $0 |
| Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment | $0 |
| Hospice | $0 |
| Orthotics (diabetics only) | $0 |
| Routine foot care (for diabetics) | $0 |
| Vision (exam and glasses every 24 months) | $0 |
| Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife) | $0 |
| Annual Out-of-Pocket Expenses per benefit year | Maximum amount |
| Pharmacy | $200 |