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Covered Benefit	Co-Payment
Outpatient Medical Care
Community Health Center Visits (Primary Care and Specialist)	$15/$22
Preventive Care Service (including Family Planning visits)	$0
Office Visits (Primary Care and Specialists)	$15/$22
Outpatient Surgery (Hospital and Ambulatory Surgery Centers)	$125
Abortion Services	$100
X-rays/Labs	$0
High Cost Imaging Services (MRI, CAT, PET)	$60
Inpatient Medical and Maternity Care (includes deliveries/surgery/labs/x-rays)	$250*
Prescription Drugs
Medication via Pharmacy (1 month supply)	Generic $12.50 Brand Preferred $25 Non-preferred Brand $50
Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply)	Generic $25 Brand Preferred $50 Non-preferred Brand $150
Contraceptives	$0
Emergency Care	$100**
Inpatient Mental Health & Substance Abuse	$250*
Outpatient Mental Health & Substance Abuse	$15
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	$250*
Short-term outpatient rehabilitation (Physical, Occupational, and Speech Therapy) Prior Authorization required for all services.	$20
Other Benefits
Ambulance (emergency or prior authorized ambulance transport only)	$0
Durable Medical Equipment, Supplies, Prosthetics, Oxygen & Respiratory Therapy Equipment	10% of cost
Hospice	$0
Orthotics (diabetics only)	$0
Routine foot care (for diabetics)	$10
Vision (exam and glasses every 24 months)	$20
Wellness (Family Planning, Nutritional Counseling, Prenatal, Nurse Midwife)	$0
Annual Out-of-Pocket Expenses per benefit year	Maximum amount
All Services (excluding Pharmacy)	$1,500
Pharmacy	$800

* Co-pay waived if transferred from another inpatient unit.

** Co-pay waived if admitted to an inpatient unit.