| Office visits |
$15 per visit |
| Well-child care |
$15 per visit |
Routine checkups
(including one gynecological exam per calendar year) |
$15 per visit |
Emergency room visits
(waived for observation stay or if admitted) |
$40 per visit |
| Maternity care |
Nothing |
| Allergy injections only |
Nothing |
| Diagnostic X-rays, laboratory tests, and other tests |
Nothing |
| Oxygen and equipment for its administration |
Nothing |
| Hearing exams |
$15 per visit |
| Routine vision exams (one exam per year) |
$15 per visit |
| Family planning and infertility services |
$15 per visit |
Chiropractic services
(up to 18 visits per calendar year for members age 16 or older) |
$15 per visit |
| Home health care, including hospice care |
Nothing |
Durable medical equipment (i.e., wheelchairs, crutches, hospital beds, and prosthetic devices, including repairs)
(up to a maximum of $15,000 per calendar year*) |
All charges after $15,000 benefit maximum has been met |
Short-term rehabilitation therapy**
(physical and occupational) |
$15 per visit |
| Speech, hearing, and language disorder treatment |
$15 per visit |