PBP_A_HNUMBER	PBP_A_PLAN_IDENTIFIER	PBP_A_BEN_COV	PBP_A_PLAN_TYPE	ORGTYPE	PBP_B14A_AUTH	PBP_B14A_BENDESC_AMO_AMP	PBP_B14A_BENDESC_AMO_CHP	PBP_B14A_BENDESC_AMO_DSM	PBP_B14A_BENDESC_AMO_HEC	PBP_B14A_BENDESC_AMO_MHC	PBP_B14A_BENDESC_AMO_NHL	PBP_B14A_BENDESC_AMO_NL	PBP_B14A_BENDESC_AMO_NTV	PBP_B14A_BENDESC_AMO_OTH	PBP_B14A_BENDESC_AMO_SC	PBP_B14A_BENDESC_EHC	PBP_B14A_BENDESC_YN	PBP_B14A_COINS_AMP_PCT	PBP_B14A_COINS_CHP_PCT	PBP_B14A_COINS_COV_AMP	PBP_B14A_COINS_COV_CHP	PBP_B14A_COINS_COV_DSM	PBP_B14A_COINS_COV_HEC	PBP_B14A_COINS_COV_MHC	PBP_B14A_COINS_COV_NHL	PBP_B14A_COINS_COV_NL	PBP_B14A_COINS_COV_NTV	PBP_B14A_COINS_COV_OTH	PBP_B14A_COINS_COV_SC	PBP_B14A_COINS_DSM_PCT	PBP_B14A_COINS_HEC_PCT	PBP_B14A_COINS_MHC_PCT	PBP_B14A_COINS_NHL_PCT	PBP_B14A_COINS_NL_PCT	PBP_B14A_COINS_NTV_PCT	PBP_B14A_COINS_OTH_PCT	PBP_B14A_COINS_PCT_AMP	PBP_B14A_COINS_PCT_CHP	PBP_B14A_COINS_PCT_DSM	PBP_B14A_COINS_PCT_HEC	PBP_B14A_COINS_PCT_MAX_AMP	PBP_B14A_COINS_PCT_MAX_DSM	PBP_B14A_COINS_PCT_MAX_HEC	PBP_B14A_COINS_PCT_MAX_MHC	PBP_B14A_COINS_PCT_MAX_OTH	PBP_B14A_COINS_PCT_MHC	PBP_B14A_COINS_PCT_NHL	PBP_B14A_COINS_PCT_NL	PBP_B14A_COINS_PCT_NTV	PBP_B14A_COINS_PCT_OTH	PBP_B14A_COINS_PCT_SC	PBP_B14A_COINS_SC_PCT	PBP_B14A_COINS_YN	PBP_B14A_COPAY_AMP_AMT	PBP_B14A_COPAY_AMP_MAX_AMT	PBP_B14A_COPAY_CHP_AMT	PBP_B14A_COPAY_DSM_AMT	PBP_B14A_COPAY_DSM_MAX_AMT	PBP_B14A_COPAY_HEC_AMT	PBP_B14A_COPAY_HEC_MAX_AMT	PBP_B14A_COPAY_MHC_AMT	PBP_B14A_COPAY_MHC_MAX_AMT	PBP_B14A_COPAY_NHL_AMT	PBP_B14A_COPAY_NL_AMT	PBP_B14A_COPAY_NTV_AMT	PBP_B14A_COPAY_OTH_AMT	PBP_B14A_COPAY_OTH_MAX_AMT	PBP_B14A_COPAY_SC_AMT	PBP_B14A_COPAY_YN	PBP_B14A_DED_AMT	PBP_B14A_DED_YN	PBP_B14A_MAXENR_AMT	PBP_B14A_MAXENR_PER	PBP_B14A_MAXENR_YN	PBP_B14A_MAXPLAN_AMT	PBP_B14A_MAXPLAN_COVB	PBP_B14A_MAXPLAN_PCT	PBP_B14A_MAXPLAN_PER	PBP_B14A_MAXPLAN_YN	PBP_B14A_NOTES	PBP_B14A_REFER_YN	PBP_B14B_AUTH	PBP_B14B_BENDESC	PBP_B14B_BENDESC_AMO	PBP_B14B_BENDESC_YN	PBP_B14B_COINS_COV_MC	PBP_B14B_COINS_COV_OI	PBP_B14B_COINS_PCT_MAXOI	PBP_B14B_COINS_PCT_MC	PBP_B14B_COINS_PCT_OI	PBP_B14B_COINS_YN	PBP_B14B_COPAY_MC_AMT	PBP_B14B_COPAY_OI_AMT	PBP_B14B_COPAY_OI_MAX_AMT	PBP_B14B_COPAY_YN	PBP_B14B_COST_SHARE	PBP_B14B_DED_AMT	PBP_B14B_DED_YN	PBP_B14B_MAXENR_AMT	PBP_B14B_MAXENR_PER	PBP_B14B_MAXENR_TYPE	PBP_B14B_MAXENR_YN	PBP_B14B_NOTES	PBP_B14B_REFER_YN	PBP_B14C_AUTH	PBP_B14C_BENDESC_AMO	PBP_B14C_BENDESC_ENHAN	PBP_B14C_BENDESC_LIM	PBP_B14C_BENDESC_NUMV	PBP_B14C_BENDESC_PER	PBP_B14C_BENDESC_YN	PBP_B14C_COINS_COV	PBP_B14C_COINS_PCT	PBP_B14C_COINS_YN	PBP_B14C_COPAY_AMT	PBP_B14C_COPAY_YN	PBP_B14C_COST_SHARE	PBP_B14C_DED_AMT	PBP_B14C_DED_YN	PBP_B14C_MAXENR_AMT	PBP_B14C_MAXENR_PER	PBP_B14C_MAXENR_TYPE	PBP_B14C_MAXENR_YN	PBP_B14C_MAXPLAN_AMT	PBP_B14C_MAXPLAN_COV	PBP_B14C_MAXPLAN_PER	PBP_B14C_MAXPLAN_TYPE	PBP_B14C_MAXPLAN_YN	PBP_B14C_NOTES	PBP_B14C_REFER_YN	PBP_B14D_AUTH	PBP_B14D_BENDESC_AMO_PE	PBP_B14D_BENDESC_AMO_PS	PBP_B14D_BENDESC_ENHAN	PBP_B14D_BENDESC_LIM_APE_YN	PBP_B14D_BENDESC_LIM_APS_YN	PBP_B14D_BENDESC_NUMPE	PBP_B14D_BENDESC_NUMPS	PBP_B14D_BENDESC_PE_PER	PBP_B14D_BENDESC_PS_PER	PBP_B14D_BENDESC_YN	PBP_B14D_COINS_COV_MCPAP	PBP_B14D_COINS_COV_MCPE	PBP_B14D_COINS_COV_PAP	PBP_B14D_COINS_COV_PE	PBP_B14D_COINS_PCT_MCPAP	PBP_B14D_COINS_PCT_MCPE	PBP_B14D_COINS_PCT_PAP	PBP_B14D_COINS_PCT_PE	PBP_B14D_COINS_YN	PBP_B14D_COPAY_AMT_MCPAP	PBP_B14D_COPAY_AMT_MCPE	PBP_B14D_COPAY_AMT_PAP	PBP_B14D_COPAY_AMT_PE	PBP_B14D_COPAY_YN	PBP_B14D_COST_SHARE	PBP_B14D_DED_AMT	PBP_B14D_DED_YN	PBP_B14D_MAXENR_AMT	PBP_B14D_MAXENR_PER	PBP_B14D_MAXENR_TYPE	PBP_B14D_MAXENR_YN	PBP_B14D_MAXPLAN_AMT	PBP_B14D_MAXPLAN_COV	PBP_B14D_MAXPLAN_PER	PBP_B14D_MAXPLAN_TYPE	PBP_B14D_MAXPLAN_YN	PBP_B14D_NOTES	PBP_B14D_REFER_YN	PBP_B14D_SEP_COST_YN
H0150	001	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2	5.00	1	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per yearOffice visit copayment could apply	2	
H0150	004	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2	5.00	1	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per yearOffice visit copayment could apply	2	
H0150	005	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per year	2	
H0150	006	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per yearOffice visit copayment could apply	2	
H0150	007	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per year	2	
H0151	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	002	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	009	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	010	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	011	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	012	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0151	013	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0154	001	1	01	01	00111		1			1		1				0010010100	1																																				2																2		2			2	20.00	7		6	1	VIVA Medicare Plus will pay up to $20 per month toward membership dues at designated sports fitness facilities for members who regularly attend.	2	00111			2						2				2	3		2				2	If an immunization is provided in the course of an office visit, an office visit copayment may apply.	2	00100	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H0302	001	1	01	01	01000		2	2	2			2	2	2		1111010001	1																																				2																2		2			2					2	MediSun members are eligible to receive a no cost fitness assessment from the Sun Health Community Education Center.Health education, nutritional training, weight management, support groups and other wellness programs are available to all members through the Sun Health Community Education Center.MediSun newsletters are sent to all members on a regular basis.MediSun members diagnosed with diabetes and/or congestive heart failure are eligible for referral to the MediSun Disease Management Programs.	1	00001			2						2	25.00			1	1		2				2	Flu and pneumonia vaccinations have no member copayment.Hepatitis B vaccincations, for those at risk, have a copayment of $25 per injection.MediSun members must receive all immunizations from their network PCP, Sun Health/MediSun Flu Shot Clinic, or network specialty care physician.Specialty care physician visits require a referral from the member's PCP.Immunizations received from non-contracted providers, including grocery stores & pharmacies, are not a covered benefit.	1	00100	2	1	2	1	3	1			2	20.00	1	3		2				2					2	The $20 copayment is for a routine annual physical examination (well woman/well man) performed by the member's PCP. If an additional evaluation and management services is needed to diagnose a medical problem identified during the routine annual physical examination, an additional office visit copayment of $10 may apply.There is no additional copayment for laboratory testing ordered as part of the routine annual physical examination.Health examinations and testing performed for insurance qualification, nursing home admittance, school attendance, employment or by court order are not a covered benefit.Routine physical examinations performed by out-of-network providers are not a covered benefit.	2	00100										2									2					2	1		2				2						Member does not pay an additional copayment for pap smears or pelvic examinationations.Members pays a $10 copayment for each PCP office visit.Members pays a $20/$30 copayment for each specialty care office visit.Benefit is limited to one pap smear and pelvic examination for screening purposes per calendar year (January 1 - December 31, 2004).Preventative health services obtained from out-of-network providers without PCP referral and prior authorization from MediSun are not covered.	2	
H0303	013	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2							2	2
H0303	015	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2							2	2
H0303	022	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0303	034	1	01	01	01000					1	1					0000000110	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	0.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0303	035	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2							2	2
H0303	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0307	004	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$40 SPC	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends upon setting where service is received:$15  PCP                $40  Specialist	2	
H0307	008	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	ImmunizationsThere is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 Primary Care Physician$40 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends upon setting where service is received:$5  PCP$40 Specialist	2	
H0307	801	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H0315	001	1	04	01													2																																																															Evercare offers the following benefits within the nursing home: Physician visits & Nurse Practitioner visits in a nursing home. Family Counsels in a nursing home.		10000	1	1	1						2				2	2		2				2	Primary Care Team: Nurse Practitioner and Primary Care PhysicianPay $0 but Office visit copay may apply. Primary Care Team: Nurse practitioner and Primary Care Physician.No copayment for Influenza and Pneumococcal vaccinations.	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: Nurse Practitioner and Primary Care Physician	1	00100										2									2					2	3		2				2						Primary Care Team: Nurse Practitioner and Primary Care Physician	1	
H0316	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0316	002	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H0350	001	1	01	01	01000			1				1			1	0010100001	1																																				2																2		2			2					2		2	10000			2						2				2	1		2				2	The following will not be covered:     Immunizations for foreign travelEnrollees pay nothing for immunization procedures; however, dependent upon place of service an office visit copay will apply.$15.00 PCP office visit copay or $25.00 Specialist office visit copay.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Enrollees pay nothing for Routine Physical Exam procedures; however, dependent upon place of service an office visit copay will apply.$15.00 PCP office visit copay or $25.00 Specialist office visit copay.	2	00001										2									2					2	1		2				2						Enrollees pay nothing for pap smear procedures; however, dependent upon place of service an office visit copay will apply.$15.00 PCP office visit copay or $25.00 Specialist office visit copay.	2	
H0351	007	1	01	01	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus. For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	008	1	01	01	01000			1	1		1				1	0100100011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	014	1	01	01	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	016	2	01	01	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	017	2	01	01	01000			2	2		2				2	0100100011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	021	2	01	01	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	023	1	01	01	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	2	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	025	1	01	01	01000				1	1	1				1	0100100110	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	1	1						2				2	1		2				2	Other immunizations covered: Tetanus. For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	026	1	01	01	01000			1	1	1	1				1	0100100111	1																																				2																2		2			2					2	Free health club membership avaliable at contracted facilities only.	2	00111	1	1	1						2				2	1		2				2	Other immunizations covered: Tetanus.For all immunizations (including pneumonia and influenza), copayments are applied as appropriate depending on the place where services are rendered.	1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Copayments are applied as appropriate depending on the place where services are rendered.  One self-referral pap smear/pelvic exam per calender year.	2	
H0351	801	1	01	01													2																																																																	00111			2	4			20		1				2	1		2				2	Copayments are applied as appropriate depending on the place where services are rendered.	1							2																				01000										2	4	4			20	20			1					2	1		2				2						Copayments are applied as appropriate depending on the place where services are rendered.	2	1
H0354	001	1	01	01	01000			2	2		2	2	2	2	2	1111100011	1																																				2																2		2			2					2	There is no copayment for Nutritional Training in a class setting. There is an office copayment of $5 for each one-on-one counseling session with a Nutritional Therapist or Diabetic Educator.Tai Chi classes - the class is free to CIGNA HealthCare for Seniors members.	2	01000			2						2	0.00			1	1		2				2	An office visit copayment applies for Hepatitis B shots.Except for flu, pneumonia and hepatitis B shots, all other medically needed injections require a $5 copayment.	2	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2	Routine physicals are covered on an annual basis. For established members, at least 365 days must have elapsed from the previous routine physical in order for a new exam to be covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral required for in-network Womens Health Specialists.Specialty services require only a referral if obtained from the CIGNA Medical Group (CMG) or contracted network providers. Specialty services obtained from non-contracted or non-network providers require prior authorization.IF PERFORMED IN THE CIGNA MEDICAL GROUPRoutine pap smears, pelvic exams and mammographies when provided as part of the annual Well Women Exam, require a copayment of $5 per Well Women exam performed by a PCP. If the Well Women exam is performed by a specialist (OBGYN), the copayment is $15.IF PERFORMED BY A CONTRACTED SPECIALIST NOT IN THE CIGNA MEDICAL GROUPRoutine pap smears, pelvic exams and mammographies when provided as part of the annual Well Women Exam, require a copayment of $35 per Well Women exam performed by a contracted, non-CMG specialist (OBGYN).	2	
H0354	009	2	01	01	01000			2	2		2	2	2	2	2	1111100011	1																																				2																2		2			2					2	There is no copayment for Nutritional Training in a class setting. There is an office copayment of $5 for each one-on-one counseling session with a Nutritional Therapist or Diabetic Educator.Tai Chi classes - the class is free to CIGNA HealthCare for Seniors members.	2	01000			2						2	0.00			1	1		2				2	An office visit copayment applies for Hepatitis B shots.Except for flu, pneumonia and hepatitis B shots, all other medically needed injections require a $5 copayment.	2	01000	2	1	2	1	3	1			2	5.00	1	2		2				2					2	Routine physicals are covered on an annual basis. For established members, at least 365 days must have elapsed from the previous routine physical in order for a new exam to be covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral required for in-network Womens Health Specialists.Specialty services require only a referral if obtained from the CIGNA Medical Group (CMG) or contracted network providers. Specialty services obtained from non-contracted or non-network providers require prior authorization.IF PERFORMED IN THE CIGNA MEDICAL GROUPRoutine pap smears, pelvic exams and mammographies when provided as part of the annual Well Women Exam, require a copayment of $5 per Well Women exam performed by a PCP. If the Well Women exam is performed by a specialist (OBGYN), the copayment is $15.IF PERFORMED BY A CONTRACTED SPECIALIST NOT IN THE CIGNA MEDICAL GROUPRoutine pap smears, pelvic exams and mammographies when provided as part of the annual Well Women Exam, require a copayment of $35 per Well Women exam performed by a contracted, non-CMG specialist (OBGYN).	2	
H0504	015	1	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All  Members may self refer to any women's health specialist who is part of their physician group	2	2
H0504	016	1	01	01	01000		2	2	2		2	2	2	2		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	2	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All Members may self refer to any women's health specialist who is part of their physician group.	2	2
H0504	017	1	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All Members may self refer to any women's health specialist who is part of their physician group.	2	2
H0504	018	1	01	01	01000		2	2	2		2	2	2	2		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	2	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All Members may self refer to any women's health specialist who is part of their physician group.	2	2
H0504	019	2	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All  Members may self refer to any women's health specialist who is part of their physician group	2	2
H0504	020	2	01	01	01000		2	2	2		2	2	2	2		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life.The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information.. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered. Other immunizations have no separate copay; if done as part of the office visit, the office visit copayment applies.	1	00111	2	1	2	1	3	1			2	10.00	1	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2	10.00	10.00			1	1		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All Members may self refer to any women's health specialist who is part of their physician group.	2	2
H0504	021	1	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life. The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered.	1	00111	1	1	2	1	3	1			2		2	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2					2	2		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All  Members may self refer to any women's health specialist who is part of their physician group.	2	
H0504	022	1	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life. The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered.	1	00111	1	1	2	1	3	1			2		2	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2					2	2		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All  Members may self refer to any women's health specialist who is part of their physician group.	2	
H0504	023	2	01	01	01000		1	1	1		1	1	1	1		1111010011	1																																				2																2		2			2					2	The Health Education/Wellness program is one feature under Blue Shield's Lifepath Connections department, which offers a unique array of services specially designed for our members that can enhance their vitality & independence, and improve their quality of life. The programs are designed to support independent living in the members' community. They include leisure lifestyle classes, member information classes, video loan, volunteer services and community health education classes as well as:  CareCall - a member can find reassurance with CareCall if a member lives alone or is homebound. On a regular, prearranged basis, the member will receive a call from another Blue Shield 65 Plus member to see if they're okay or whether they need something, or just to chat. CareXchange - this program helps provide opportunities for members to stay active and help others. If the member lives in an area in which CareXchange is available, they can volunteer to provide simple non-medical services to Blue Shield 65 Plus members who need help with routine activities like transportation to & from doctor appointments, light housekeeping, & yard work. - Community health education & wellness activities: including classes, screenings, demonstrations in select locales promoting healthy lifestyle, preventive & wellness behaviors. Phone- In programs offer all members the opportunity to participate in educational programs from the convenience of their own homes.  - In addition to the Nurse Hotline, Nurse Chat is also available.  Our online nurse chat service offers an anonymous one-on-one dialogue with a registered nurse, 24 hrs/day. A nurse will respond to your general health questions & direct you to online resources for more information. When you're done, you can have a transcript of your online conversation e-mailed to you. The transcript w/include all the info & links that the nurse has provided for easy reference.For 2004 Centers for Health Improvement (CHI) will provide the following to Blue Shield 65 Plus members: Health Management Programs Joint Health Arthritis Self-Care Program  Chart Your Course Diabetes Management Program. Care Package is only offered within the plan service area. Care package has multiple elements which include: following each covered stay in a network hospital or other network facility (SNF) the mbr is covered for 8 hours w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide). -following a covered outpatient surgical procedure performed by a network provider, the mbr is covered for 4 hrs w/a home health aide &/or homemaker, w/homemaker visits available in 4-hour increments (from a certified homemaker) & home health aide visits available in 2-hour increments (from a certified home health aide).  Help at Home After your hospital stay or qualifying o/p procedure we can arrange for you to receive visits from a home health aide (who can assist you with activities of daily living, such as eating, bathing and dressing), or from a homemaker (who can prepare light meals, complete light housekeeping chores, or run errands for you up to 10 miles from your home.)   If a visit is less than 4 hours or if the mbr is readmitted to the hospital before the home visits associated with the covered hospital stay or covered procedure take place, the unused hours may not be carried forward for future use. The mbr is eligible for the home visits associated w/the most recent covered hospital stay or covered o/p procedure. The mbr can access the benefit during the first 4 weeks after discharge. These services are in addition to any services provided by home health aides when a skilled level of care is also necessary.  Also included is a pre-surgical guided imagery tape (if requested prior to procedure)	2	00111			2						2				2	3		2				2	Covered according to Medicare guidelines. Travel immunizations (immunizations recommended by the CDC when traveling out of the country) are not covered.	1	00111	1	1	2	1	3	1			2		2	2		2				2					2	Components/testing performed during an annual routine physical exam vary according to medical indication and clinical guidelines as determined by the Personal Physician/Physician Group	2	01000										2									2					2	2		2				2						Covered according to Medicare guidelines. For the Well Woman Exam, which includes pap smears, breast examinations and pelvic examinations, All  Members may self refer to any women's health specialist who is part of their physician group.	2	
H0523	002	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H0523	022	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H0523	025	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H0523	801	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H0524	001	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			10.00	0.00	10.00	0.00	10.00			0.00	0.00	10.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $23.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumococcal vaccines,  immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	10.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $23.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	10.00			1	1		2				2						B-14d-base 4There is a $10 ( $23.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	002	2	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			10.00	0.00	10.00	0.00	10.00			0.00	0.00	10.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $23.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumococcal vaccines,  immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	10.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $23.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	10.00			1	1		2				2						B-14d-base 4There is a $10 ( $23.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	003	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			10.00	0.00	10.00	0.00	10.00			0.00	0.00	10.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $23.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumococcal vaccines,  immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	10.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $23.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	10.00			1	1		2				2						B-14d-base 4There is a $10 ( $23.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	006	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			10.00	0.00	10.00	0.00	10.00			0.00	0.00	10.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $23.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumococcal vaccines,  immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	10.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $23.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	10.00			1	1		2				2						B-14d-base 4There is a $10 ( $23.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	008	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			20.00	0.00	20.00	0.00	20.00			0.00	0.00	20.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $33.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	20.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $33.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	20.00			1	1		2				2						B-14d-base 4There is a $20 ( $33.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	009	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			20.00	0.00	20.00	0.00	20.00			0.00	0.00	20.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $33.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	20.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $33.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	20.00			1	1		2				2						B-14d-base 4There is a $20 ( $33.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	010	2	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			20.00	0.00	20.00	0.00	20.00			0.00	0.00	20.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $33.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	20.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $33.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	20.00			1	1		2				2						B-14d-base 4There is a $20 ( $33.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	013	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			20.00	0.00	20.00	0.00	20.00			0.00	0.00	20.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $33.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	20.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $33.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	20.00			1	1		2				2						B-14d-base 4There is a $20 ( $33.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	014	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			20.00	0.00	20.00	0.00	20.00			0.00	0.00	20.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $33.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	20.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $33.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	20.00			1	1		2				2						B-14d-base 4There is a $20 ( $33.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	015	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			10.00	0.00	10.00	0.00	10.00			0.00	0.00	10.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $23.50 will be charged.Copays apply towards the $3,000 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumococcal vaccines,  immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	10.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $23.50 will be charged.  Copays apply towards the $3,000 out of pocket maximum.	2	01000										2									2	10.00	10.00			1	1		2				2						B-14d-base 4There is a $10 ( $23.50 copay if member chooses to be billed)  office visit for a pelvic exam done in the doctors office.  there is a $10 ($23.50 copay if member chooses to be billed)  lab service copay for the pap smear.Copays apply towards the out-of-pocket maximum of $3,000.	2	2
H0524	801	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			420.00	0.00	40.00	0.00	40.00			0.00	0.00	40.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $53.50 will be charged.Copays apply towards the $1500 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	40.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $53.50 will be charged.  Copays apply towards the $1500 out of pocket maximum.	2	01000										2									2					2	1		2				2						There is no copayment for the actual procedure itself.  The doctor office copaymemt does apply if done in the doctors office or the doctor is involved with the procedure.	2	
H0524	802	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			420.00	0.00	40.00	0.00	40.00			0.00	0.00	40.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $53.50 will be charged.Copays apply towards the $1500 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pnemoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	40.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $53.50 will be charged.  Copays apply towards the $1500 out of pocket maximum.	2	01000										2									2					2	1		2				2						There is no copayment for the actual procedure itself.  The doctor office copaymemt does apply if done in the doctors office or the doctor is involved with the procedure.	2	
H0524	803	2	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			420.00	0.00	40.00	0.00	40.00			0.00	0.00	40.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $53.50 will be charged.Copays apply towards the $1500 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	40.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $53.50 will be charged.  Copays apply towards the $1500 out of pocket maximum.	2	01000										2									2					2	1		2				2						There is no copayment for the actual procedure itself.  The doctor office copaymemt does apply if done in the doctors office or the doctor is involved with the procedure.	2	
H0524	804	2	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2			420.00	0.00	40.00	0.00	40.00			0.00	0.00	40.00			0.00	1		2			2					2	B-14a-base 6KP covers a number of group health education classes  at no charge including ; cardiovascular care, smoking cessation, living with chronic conditions and depression.  Individual visits for nutritional consulation, disease management, diabetes etc. will be at the Doctor's office visit copay.If a member chooses to be billed rather than pay at the time of an individual visit a copay of $53.50 will be charged.Copays apply towards the $1500 out-of-pocket maximum.	2	01000			2						2				2	1		2				2	Other than influenza and pneumoccocal vaccines, immunizations must be prescribed by a Plan Physician and approved for use by the FDA.	1	01000	2	1	1			1			2	40.00	1	2		2				2					2	B-14c-base 3Physical examinations and other services and supplies are excluded when (a) required for obtaining or maintaining employment or participation in employee programs,or (b) required for insurance or licensing, or (c) on court order or required for parole or probation are not covered.  This exclusion does not apply if a Plan physician determines that the services and supplies are medically necessary.If member chooses to be billed rather than pay the copay at the time of the visit a copay of $53.50 will be charged.  Copays apply towards the $1500 out of pocket maximum.	2	01000										2									2					2	1		2				2						There is no copayment for the actual procedure itself.  The doctor office copaymemt does apply if done in the doctors office or the doctor is involved with the procedure.	2	
H0532	001	1	01	01	00111				1			1				0110000000	1																																				2																2		2			2					2		1	00111			2						2				2	2		2				2		1	01000	1	1	1			1			2	15.00	1	2		2				2					2		2	00111		1	01		2		1		3	1									2	0.00	15.00	0.00		1	2		2				2					2		1	2
H0532	002	1	01	01	00111				1			1				0110000000	1																																				2																2		2			2					2		1	00111			2						2				2	2		2				2		1	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	00111		1	01		2		1		1	1									2	0.00	10.00	0.00		1	2		2				2					2		1	2
H0538	001	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	002	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	003	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	004	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	005	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	007	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	008	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	009	1	01	01	00111		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00111			2						2				2	1		2				2		1	00111	1	1	2	1	3	1			2		2	1		2				2					2		1	00111										2									2					2	1		2				2							2	
H0538	802	1	01	01													2																																																																	00111			2	2			13		1				2	1		2				2		1							2																				00111										2	2	2			13	13			1					2	1		2				2							2	2
H0540	001	1	09	04													2																																																																	01000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	SecurityChoice members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	2	01000										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0540	005	1	09	04													2																																																																	01000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	SecurityChoice members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	2	01000										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0540	007	1	09	04													2																																																																	01000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	SecurityChoice members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	2	01000										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0540	009	1	09	04													2																																																																	01000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	SecurityChoice members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	2	01000										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0540	010	1	09	04													2																																																																	01000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	SecurityChoice members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	2	01000										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0543	001	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	004	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	007	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	013	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	019	1	01	01	01000					2						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	022	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	026	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	028	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	029	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	032	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	035	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	036	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	9.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	038	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	9.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	040	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	9.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	046	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	049	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	050	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	060	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	065	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	070	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	071	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	072	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	073	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	074	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	075	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	9.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	076	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	9.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	077	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	078	1	01	01	01000					1	1					0000000110	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine.  No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	0.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists.  Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	079	1	01	01	01000					1	1					0000000110	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	0.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	080	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	3.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	081	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	3.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	082	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00110	2	2	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	802	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0543	803	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0544	001	1	05	01	00110		1	1		1				1		1000010101	1																																				2																2		2			2					2	$0 for all health education/wellness programs and the following:Anticoagulation Clinic - monitors members taking anticoagulants to reduce risks of internal bleeding and other complications.Comprehensive Care Clinic - coordinates and manages care for members who have complex health problems and need intense medical attention.Diabetes Clinic - focuses on group and individual diabetes education, insulin start education, management of the complex diabetic member, orthotics, and wound care.Hospitalist Program - members are monitored during their hospital stay by these highly trained specialists.Physician House Call Program - dedicated to seeing frail members in their home the day after discharge from the hospital (member must meet certain criteria).Pre-Operative Clinic - members are seen by our hospitalist team prior to surgery to ensure the member is ready for scheduled surgery.Winning In The Second Half (WISH) Program - members may take advantage of strength training benefits at local fitness clubs.	1	01000	1	1	1						2				2	2		2				2	$0 for Hepatitis B vaccine for those at high risk of contracting the disease.  $0 for other vaccines if you are at risk, such as anti-rabies vaccine if you have been exposed to rabies.$0 for B-12 injections at the providers office.  Not covered if received at a participating pharmacy.Travel immunizations not covered.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2						$0 for each Medicare covered pap smear/pelvic exam; 1 every 2 years.Members are eligible for 1 exam every year if at high risk of cervical cancer, have had an abnormal pap test, or are of child bearing age.No referral required as long as services are obtained from a California Medicare Advantage provider.	2	
H0545	001	1	01	01	00001		1					1				0010010000	1																																				2																2		2			2					2		2	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Section B-14c Routine Physical Exams-Base 1.  Members are covered for one (1) routine physical exam per calendar year.  Routine physical exams are conducted by the Primary Care Physician (PCP) in his/her office.  The copayment for PCP, $5, applies to this service.	2	00111	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		1	
H0545	002	1	01	01	00001		1					1				0010010000	1																																				2																2		2			2					2		2	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Section B-14c Routine Physical Exams-Base 1.  Members are covered for one (1) routine physical exam per calendar year.  Routine physical exams are conducted by the Primary Care Physician (PCP) in his/her office.  The copayment for PCP, $5, applies to this service.	2	00111	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		1	
H0545	005	1	01	01	00001		1					1				0010010000	1																																				2																2		2			2					2		2	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Section B-14c Routine Physical Exams-Base 1.  Members are covered for one (1) routine physical exam per calendar year.  Routine physical exams are conducted by the Primary Care Physician (PCP) in his/her office.  The copayment for PCP, $5, applies to this service.	2	00111	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		1	
H0562	002	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	009	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	010	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	011	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	012	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	017	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	019	2	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	029	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	031	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	032	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	033	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	036	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	037	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	039	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	040	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	041	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	042	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	043	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0562	801	1	01	01	01000		2	2	2		1	2	2		2	0111110011	1																																				2																2		2			2					2		2	00111	1	2	1						2				2	2		2				2	Base - 2 (Copayments)- Pneumococcal and Flu vaccines require $0 copayment.	1	00101	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2					2	2		2				2						Base 4 - (Authorizations)- Members may self refer for a screening pap smear which includes a screening pelvic examination and clinical breast cancer examination. A referral from a Primary Care Physician is not required; however, the OB/GYN specialist must be a part of the Contracting Physician Group.	2	
H0564	003	1	02	01													2																																																																	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	2	1	2	1	3	1			2	20.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $20 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	004	1	02	01													2																																																																	10100	1	1	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $15 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	005	1	02	01													2																																																																	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	2	1	2	1	3	1			2	15.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $15 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	006	1	02	01													2																																																																	10100	1	1	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $5 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	007	1	02	01													2																																																																	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	2	1	2	1	3	1			2	10.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $10 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	009	1	02	01													2																																																																	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	2	1	2	1	3	1			2	15.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $15 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	023	2	02	01													2																																																																	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	00100	2	1	2	1	3	1			2	15.00	1	2		2				2					2	Senior Secure members are covered for one routine physical exam each year with a $15 copay (not including lab services). Routine physical exams are performed without relationship to treatment or diagnosis for specific illness, symptom, complaint or injury and are NOT required by third parties (i.e., insurance companies, business establishments, governmental agencies).	1	00100										2									2					2	3		2				2						There is no copayment for these services. However, a copayment may apply for an associated office visit.	2	
H0564	801	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0564	802	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0564	803	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0564	804	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0564	805	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0564	807	1	02	01	01000										2	0000100000	1																																				2																2		2			2					2		2	10100	1	2	1						2				2	3		2				2	Hepatitis B vaccinations for persons at risk and immunizations required because of an injury or risk of infection will be covered. They must be authorized by the Member's Primary Care Physician and/or Medical Group.There is no copayment for immunizations. However, a copayment may apply for an associated office visit.	1	10100	2	1	1			1			2	5.00	1	2		2				2					2	The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	1	10100										2									2	5.00	5.00			1	2		2				2						The member may receive authorization from their Primary Care Physician or another provider designated by the member's Medical Group.	2	2
H0571	001	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	2		2				2	Immunization as recommended by the US Public Health Service.No referral necessary for influenza vaccine.	1	01000	1	1	1			1			2	7.00	1	2		2				2					2	The plan only has one $7.00 copay for routine physical exams.There is no additional doctor office copayment for this benefit.	2	00100	1	1	11	1	1					1									2					2	2		2				2					2		2	
H0571	002	2	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	2		2				2	Immunization as recommended by the US Public Health Service.No referral necessary for influenza vaccine.	1	01000	1	1	1			1			2	7.00	1	2		2				2					2	The plan only has one $7.00 copay for routine physical exams.There is no additional doctor office copayment for this benefit.	2	00100	1	1	11	1	1					1									2					2	2		2				2					2		2	
H0571	801	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	2		2				2	Immunization as recommended by the US Public Health Service.No referral necessary for influenza vaccine.	1	01000	1	1	1			1			2	7.00	1	2		2				2					2	The plan only has one $7.00 copay for routine physical exams.There is no additional doctor office copayment for this benefit.	2	00100	1	1	11	1	1					1									2					2	2		2				2					2		2	
H0609	002	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office vist cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2							2	2
H0609	003	1	01	01													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office vist cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2							2	2
H0609	006	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office vist cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2							2	2
H0609	007	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office vist cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2							2	2
H0609	008	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0609	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H0630	004	1	01	01	00110			1	1			1	1		1	0111100001	1																																				2				10.00	15.00	0.00	100.00				0.00	15.00			15.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	1	1						2	0.00	0.00	15.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	1	1	11	1	1					1									2	0.00	0.00	15.00	15.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0630	006	1	02	01	00110			1	1			1	1		1	0111100001	1																																				2				10.00	10.00	0.00	100.00				0.00	10.00			10.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Kaiser Permanente offers Senior Advantage Gold or Group Plan members a fitness benefit called SilverSneakers.  This benefit features the SilverSneakers exercise classes and a free basic membership to any of the participating facilities.  The benefit does not include coverage for additional fees that may be required for other services a the fitness center (i.e., court fees for racquetball, tennis, etc.)  This benefit is not a part of the Health Education/Wellness department and therefore the Membership in Health Club/Fitness Class category was not selected in this category.  The fitness benefit is a spearate benefit category.  7.29.03Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	1	1						2	0.00	0.00	10.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	1	1	11	1	1					1									2	0.00	0.00	10.00	10.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0630	007	2	01	01	00110			2	2			2	2		2	0111100001	1																																				2				10.00	15.00	0.00	100.00				0.00	15.00			15.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	2	1						2	0.00	0.00	15.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	2	2	11	1	1					1									2	0.00	0.00	15.00	15.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0630	009	2	02	01	00110			1	1			1	1		1	0111100001	1																																				2				10.00	10.00	0.00	100.00				0.00	10.00			10.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Kaiser Permanente offers Senior Advantage Gold or Group Plan members a fitness benefit called SilverSneakers.  This benefit features the SilverSneakers exercise classes and a free basic membership to any of the participating facilities.  The benefit does not include coverage for additional fees that may be required for other services a the fitness center (i.e., court fees for racquetball, tennis, etc.)  This benefit is not a part of the Health Education/Wellness department and therefore the Membership in Health Club/Fitness Class category was not selected in this category.  The fitness benefit is a spearate benefit category.  7.29.03Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	1	1						2	0.00	0.00	10.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	1	1	11	1	1					1									2	0.00	0.00	10.00	10.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0630	801	1	01	01	00110			1	1			1	1		1	0111100001	1																																				2				10.00	20.00	0.00	100.00				0.00	20.00			20.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Kaiser Permanente offers Senior Advantage Gold or Group Plan members a fitness benefit called SilverSneakers.  This benefit features the SilverSneakers exercise classes and a free basic membership to any of the participating facilities.  The benefit does not include coverage for additional fees that may be required for other services a the fitness center (i.e., court fees for racquetball, tennis, etc.)  This benefit is not a part of the Health Education/Wellness department and therefore the Membership in Health Club/Fitness Class category was not selected in this category.  The fitness benefit is a spearate benefit category.  7.29.03Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	1	1						2	0.00	0.00	20.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	1	1	11	1	1					1									2	0.00	0.00	20.00	20.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0630	802	2	01	01	00110			2	2			2	2		2	0111100001	1																																				2				10.00	20.00	0.00	100.00				0.00	20.00			20.00	1		2			2					2	Health Education and WellnessEach new Kaiser Permanente member may request the Healthwise Handbook to use as a patient reference for self-care and to use as advice for when to call KP for a medical appointment.Smoking Cessation Program - a self-referred voluntary program that covers behavior change education and pharmaceutical aids for smoking cessation.  Bupropion SR (Zyban) is covered under the OP prescription drug benefit if the member enrolls in one of Kaiser Permanente's free smoking cessation classes or the State of Colorado Smoker's Quit Line.Kaiser Permanente offers a variety of health education classes, such as stress reduction, yoga, getting better sleep, chronic pain, CPR, cholesterol classes, family caregiver workshops, living with heart disease, etc.  The fees vary based on the class.  The class schedule is published quarterly in the member newsletter.  Some classes are joint programs with Kaiser Permanente and community associations These classes are voluntary health education classes.Kaiser Permanente also offers group education classes related to a specific condition or disease.  The copayment for these classes may range from $0 to no more than $10 per visit.  Examples include Diabetes Ed and Cholesterol Ed.Kaiser Permanente offers Senior Advantage Gold or Group Plan members a fitness benefit called SilverSneakers.  This benefit features the SilverSneakers exercise classes and a free basic membership to any of the participating facilities.  The benefit does not include coverage for additional fees that may be required for other services a the fitness center (i.e., court fees for racquetball, tennis, etc.)  This benefit is not a part of the Health Education/Wellness department and therefore the Membership in Health Club/Fitness Class category was not selected in this category.  The fitness benefit is a spearate benefit category.  7.29.03Weight Management 8.04.03The KP Weight Management Program - $100 for 5 visits.  This fee includes 2 seminars that the member may choose to attend.	1	00110	1	2	1						2	0.00	0.00	20.00	1	3		2				2	ImmunizationsAn office visit copay may apply if additional medical services are provided.  No copay for office visits specifically for pneumococcal pneumonia, flu or hepatitis B vaccine.  Kaiser Permanente offers Travel Clinic benefits including immunizations for overseas travel.	1	01000	2	1	2	1	3	1			2		2	3		2				2					2	Routine Physicals - from the member's primary care provider do not require authorization or referral.	2	00110	2	2	11	1	1					1									2	0.00	0.00	20.00	20.00	1	3		2				2					2	Pap/PelvicNo office visit copay for pap smears/pelvic exams included in preventive/routine physical appointment.  Office visit copay applies for pap smears/pelvic exams included in all other office visits.  Members may self-refer for all routine OB/GYN visits.	1	2
H0710	001	1	04	01													2																																																															Evercare offers the following benefits within the nursing home: Physician visits & Nurse Practitioner visits in a nursing home. Family Counsels in a nursing home.		10100	1	1	1						2				2	3		2				2	Primary Care Team: Nurse Practitioner and Primary Care PhysicianNo copayment for Influenza and Pneumococcal vaccinations. But Office visit copay may apply.	1	10100	1	1	2	1	3	1			2		2	3		2				2					2	Primary Care Team: Nurse Practitioner and Primary Care PhysicianCopayment is $0 if services are provided in an institutional facility. There may be a $10 office visit copay if services are provided by a participating provider in a non-institutional facility.	1	10100										2									2					2	3		2				2						Primary Care Team: Nurse Practitioner and Primary Care PhysicianCopayment is $0 if services are provided in an institutional facility. There may be an office visit copay if services are provided by a participating provider in a non-institutional facility.Enrollees maybe charged copayment/coinsurance depending on services received and place of service.	1	
H0752	002	1	01	01	01000		1	1	1		1	1				0110010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H0755	001	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H0755	010	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H0755	011	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H0755	012	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H0755	013	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H0755	014	1	01	01	00001		2	2			2					0000010011	1																																				2																2		2			2					2		1	00100	1	2	1						2				2	3		2				2	Separate office visit copay may apply. No office copay applies if visit is solely for immunizations.Other immunizations covered - HEP AHEP BTetanusDiphtheriaMMR	1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Separate office visit copay will apply.	2	
H1013	011	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1013	012	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1013	019	2	01	01	00001		2	2	2			2	2		2	0111110001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1013	021	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1016	001	1	01	01	01000						1	1	1	1	1	1011100010	1																																				2																2		2			2					2	No copayment for newsletter and nursing hotline.  AvMed pays a portion of the enrollment and weekly meeting fees for Weight Watchers.  Join any Weight Watchers group, reach your goal weight, stay in the maintenance program for six weeks, and AvMed will reimburse all fees paid--including enrollment and weekly meeting fees, for a period of one year.  Smoking cessation--the plan will reimburse $29.50, the cost of the smoking cessation kit, if the member quits smoking.	2	01000			2						2	0.00			1	3		2				2	No referral necessary for network providers.  For pneumococcal and influenza immunizations, no copay and no separate office visit cost share.  For all other immunizations, including Hepatitis B, no copay but separate office visit cost share does apply.	2	01000	1	1	1			1			2	0.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2	0.00	0.00	0.00		1	1		2				2					2	$0 copay for the Pap Smear each year.  $0 copay for the Pelvic Exam each year.  No referral necessary for network providers; follow-up visits require referral and additional copay may apply.  Office visit copayments apply for first visit.	2	2
H1016	002	1	01	01	01000						1	1	1	1	1	1011100010	1																																				2																2		2			2					2	No copayment for newsletter and nursing hotline.  AvMed will pay a portion of the enrollment and weekly meeting fees for Weight Watchers.  Join any Weight Watchers group, reach your goal weight, stay in the maintenance program for six weeks, and AvMed will reimburse all fees paid--including enrollment and weekly meeting fees, for a period of one year.  Smoking cessation--the plan will reimburse $29.50, the cost of the smoking cessation kit, if the member quits smoking.	2	01000			2						2	0.00			1	3		2				2	No referral necessary for network providers.  For pneumococcal and influenza immunizations, no copay and no separate office visit cost share.  For all other immunizations, including Hepatitis B, no copay but separate office visit cost share does apply.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2	0.00	0.00	0.00		1	1		2				2					2	$0 copay for the Pap Smear each year.  $0 copay for the Pelvic Exam each year.  No referral necessary for network providers; follow-up visits require referral and additional copay may apply.  Office visit copayments apply for first visit.	2	2
H1016	017	2	01	01	01000						2	2	2	2	2	1011100010	1																																				2																2		2			2					2	No copayment for newsletter and nursing hotline.  AvMed pays a portion of the enrollment and weekly meeting fees for Weight Watchers.  Join any Weight Watchers group, reach your goal weight, stay in the maintenance program for six weeks, and AvMed will reimburse all fees paid--including enrollment and weekly meeting fees, for a period of one year.  Smoking cessation--the plan will reimburse $29.50, the cost of the smoking cessation kit, if the member quits smoking.	2	01000			2						2	0.00			1	3		2				2	No referral necessary for network providers.  For pneumococcal and influenza immunizations, no copay and no separate office visit cost share.  For all other immunizations, including Hepatitis B, no copay but separate office visit cost share does apply.	2	01000	2	1	1			1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2	0.00	0.00	0.00		1	1		2				2					2	$0 copay for the Pap Smear each year.  $0 copay for the Pelvic Exam each year.  No referral necessary for network providers; follow-up visits require referral and additional copay may apply.  Office visit copayments apply for first visit.	2	2
H1016	018	1	01	01	01000						1	1	1	1	1	1011100010	1																																				2																2		2			2					2	No copayment for newsletter and nursing hotline.  AvMed pays a portion of the enrollment and weekly meeting fees for Weight Watchers.  Join any Weight Watchers group, reach your goal weight, stay in the maintenance program for six weeks, and AvMed will reimburse all fees paid--including enrollment and weekly meeting fees, for a period of one year.  Smoking cessation--the plan will reimburse $29.50, the cost of the smoking cessation kit, if the member quits smoking.	2	01000			2						2	0.00			1	3		2				2	No referral necessary for network providers.  For pneumococcal and influenza immunizations, no copay and no separate office visit cost share.  For all other immunizations, including Hepatitis B, no copay but separate office visit cost share does apply.	2	01000	1	1	1			1			2	0.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2	0.00	0.00	0.00		1	1		2				2					2	$0 copay for the Pap Smear each year.  $0 copay for the Pelvic Exam each year.  No referral necessary for network providers; follow-up visits require referral and additional copay may apply.  Office visit copayments apply for first visit.	2	2
H1019	001	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	002	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	004	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reduction of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	005	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	006	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	007	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.Members are also entitled to $15 monthly produce voucher on health maintenance and enhancing produce such as grains, vegetables, fruits, milk products, meats, fish and other products outlined by USDA Dietary Guidelines. Vouchers are for use at participating locations and not redeemable for cash. Vouchers must be used in the current month given and cannot be carried over.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	008	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reduction of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.Members are also entitled to $15 monthly produce voucher on health maintenance and enhancing produce such as grains, vegetables, fruits, milk products, meats, fish and other products outlined by USDA Dietary Guidelines. Vouchers are for use at participating locations and not redeemable for cash. Vouchers must be used in the current month given and cannot be carried over.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	010	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	2		2				2					2		2	2
H1019	011	1	01	01	10000	1	1	1	1	1		1	1	1		1111011101	1																																				2																2		2			2					2	Access to Benefit offered at a reduced rate. Contact Plan for details. Health Education/ Wellness has up to 20% reduction of UCR. Newsletter is offered at no cost to the member. Nutritional Training has up to 20% reduction of UCRAlternative Medicine Program has up to a 20% reduction of UCR including Acupuncture, Massage Therapy, and other services.Health Club Fees & Fitness Classes have reductions of 20%-60% off membership fees.Other preventive services include Positive Change hypnosis, Magentic Therapy (reductions from 10%-60% on UCR)Additional reductions available up to 10% to 60% of UCR including vision, dermatology, hearing, cosmetic surgery, medical ID jewelry, open MRI, laservision correction, weight control and Mental Health addiction.	2	00111			2						2	0.00			1	2		2				2		1	00111	1	1	1			1			2	0.00	1	2		2				2					2		1	00111	1	1	11	2	2	1	1	3	3	1									2	20.00	20.00	20.00	20.00	1	2		2				2					2		2	2
H1026	001	1	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2	Highlights of Your SilverSneakers Fitness Program Membership The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Your membership allows access to participating full-service fitness centers throughout your area. Please refer to the Provider Directory for a fitness center in your area. While each fitness center may offer different amenities, care has been taken to ensure that all locations provide a variety of exercise options. The SilverSneakers Fitness Program Offers:          Easy enrollment at a fitness center located conveniently near you         No initiation fee, no contract, and no hassles         SilverSneakers Classes-a workout with seated support designed to improve your body's strength and flexibility         Senior AdvisorsSM, your contact for information and personalized, friendly service          A great opportunity to improve your health while meeting new friends! Most Medicare-eligible persons who have joined the SilverSneakers Fitness Program experience one or more of the following benefits:         Increased energy         Lower blood pressure         Improved balance         Enhanced social well-being         Increased circulation          Greater flexibility	2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1026	002	1	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2		2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1026	004	1	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2		2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1026	008	2	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2	Highlights of Your SilverSneakers Fitness Program Membership The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Your membership allows access to participating full-service fitness centers throughout your area. Please refer to the Provider Directory for a fitness center in your area. While each fitness center may offer different amenities, care has been taken to ensure that all locations provide a variety of exercise options. The SilverSneakers Fitness Program Offers:          Easy enrollment at a fitness center located conveniently near you         No initiation fee, no contract, and no hassles         SilverSneakers Classes-a workout with seated support designed to improve your body's strength and flexibility         Senior AdvisorsSM, your contact for information and personalized, friendly service          A great opportunity to improve your health while meeting new friends! Most Medicare-eligible persons who have joined the SilverSneakers Fitness Program experience one or more of the following benefits:         Increased energy         Lower blood pressure         Improved balance         Enhanced social well-being         Increased circulation          Greater flexibility	2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1026	009	2	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2		2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1026	011	2	01	01	01000	1	1	1	1	1		1				0110011101	1																																				2																2		2			2					2		2	00001			2						2				2	1		2				2	Doctor office visit copayment may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Doctor office visit copay applies.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Doctor office visit copayment applies.No referral necessary for network providers.	2	
H1032	002	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	004	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	006	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	008	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	1	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	010	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	012	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	014	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	019	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1032	021	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	025	1	01	01	01000		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	1	1	2	1	3	1			2	20.00	1	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	028	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	029	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	030	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	031	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1032	032	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1032	033	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00100	2	1	2	1	3	1			2		2	2		2				2					2		1	01000										2									2					2	2		2				2							2	
H1034	001	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B-14a-Health Ed/Wellness: Base 7Over the Counter Medications (OTC)-With your America's Health Choice Treasure Coast Plan membership, you also receive $25 quaterly on the over the counter medications. This consists of supplemental vitamins, pain relievers, anit-fungal creams, antacids, fist aid, cough and allergy products. You will recieve the generic equivalent of these OTC products through our mail order service only. Please contact the plan for additional details. Any unused amount cannot be carried over to the next quarter.	2	00100			2						2	25.00			1	1		2				2	Section B-14b-Immunizations: Base 3You must obtain Immunizations at your Primary Care Center.	1	00100	1	1	1			1			2		2	2		2				2					2	Section B-14c-Routine Phys: Base 4You must obtain Physical Exams at your Primary Care Center.	1	01000										2									2	0.00	20.00			1	2		2				2						Section B-14D-Pap/Pelvic: Base 5You pay $0 for a Medicare-covered Pelvic Exam performed by a staff network provider.You pay $20 for a Medicare-covered Pelvic Exam performed by a non-staff network provider.	2	2
H1034	003	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B-14a-Health Ed/Wellness: Base 7Over the Counter Medications (OTC)-With your America's Health Choice Palm Beach Plan membership, you also receive $25 quaterly on the over the counter medications. This consists of supplemental vitamins, pain relievers, anit-fungal creams, antacids, fist aid, cough and allergy products. You will recieve the generic equivalent these OTC products through our mail order service only. Please contact the plan for additional details. Any unused amount cannot be carried over to the next quarter.	2	00100			2						2				2	2		2				2	Section B-14i-Immunizations: Base 3You must obtain Immunizations at your Primary Care Center.	1	00100	1	1	1			1			2		2	2		2				2					2	Section B-14C-Routine Phys: Base 4You must obtain Physical Exams at your Primary Care Center.	1	01000										2									2	0.00	20.00			1	2		2				2						Section B-14D-Pap/Pelvic: Base 5You pay $0 for a Medicare-covered Pelvic Exam performed by a staff network provider.You pay $20 for a Medicare-covered Pelvic Exam performed by a non-staff network provider.	2	2
H1034	004	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B-14a-Health Ed/Wellness: Base 7Over the Counter Medications (OTC)-With your America's Health Choice Broward Plan membership, you also receive $25 quaterly on the over the counter medications. This consists of supplemental vitamins, pain relievers, anit-fungal creams, antacids, fist aid, cough and allergy products. You will recieve the generic equivalent of these OTC products through our mail order service only. Please contact the plan for additional details. Any unused amount cannot be carried over to the next quarter.	2	00100			2						2				2	2		2				2	Section B-14b-Immunizations: Base 3You must obtain Immunizations at your Primary Care Center.	1	00100	1	1	1			1			2		2	2		2				2					2	Section B-14C-Routine Phys: Base 4You must obtain Physical Exams at your Primary Care Center.	1	01000										2									2	0.00	20.00			1	2		2				2						Section B-14D-Pap/Pelvic: Base 5You pay $0 for a Medicare-covered Pelvic Exam performed by a staff network provider.You pay $20 for a Medicare-covered Pelvic Exam performed by a non-staff network provider.	2	2
H1035	002	1	01	01	00111			1	1			1	1			0111000001	1																																				2																2		2			2					2		1	00110			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						When a pap/pelvic is performed by a PCP the copay is $10.When a pap/pelvic is performed by a Specialist the copay is $25.	2	
H1035	004	2	01	01	00111			1	1			1	1			0111000001	1																																				2																2		2			2					2		1	00110			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						When a pap/pelvic is performed by a PCP the copay is $10.When a pap/pelvic is performed by a Specialist the copay is $25.	2	
H1035	005	1	01	01	00111			1	1			1	1			0111000001	1																																				2																2		2			2					2		1	00110			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						When a pap/pelvic is performed by a PCP the copay is $10.When a pap/pelvic is performed by a Specialist the copay is $25.	2	
H1036	011	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $25 Specialist	2	
H1036	016	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.                $5 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $30 Specialist	2	
H1036	025	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $30 Specialist	2	
H1036	034	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is rec                $0 PCP$5 SPC	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $5 Specialist	2	
H1036	035	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$20 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP$20 Specialist	2	
H1036	037	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$30 SPC	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $15 PCP $30 SPC	2	
H1036	040	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership & fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received                $0 PCP $25 Specialist	2	
H1036	044	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	ImmunizationsThere is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.                $10 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $10 PCP $30 Specialist	2	
H1036	047	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $30 Specialist	2	
H1036	048	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $30 Specialist	2	
H1036	050	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$40 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $40 Specialist	2	
H1036	052	1	01	01	01000					1		1		1		1010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.Health Education/Wellness: Nutritional Supplement Benefit:Member can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $25 Specialist	2	
H1036	053	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	2		2				2							2	
H1036	054	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Member can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	2		2				2							2	
H1036	055	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	ImmunizationsThere is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$20 SPC	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $20 SPC	2	
H1036	056	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	ImmunizationsThere is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$20 SPC	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $20 SPC	2	
H1036	058	1	01	01	01000					1		1		1		1010000100	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.Member can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$20 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	3		2				2						Copay amount depends on setting where service is received: $0 PCP $20 Specialist	2	
H1036	059	1	01	01	01000					1		1		1		1010000100	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.Member can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$20 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	3		2				2						Copay amount depends on setting where service is received: $0 PCP $20 Specialist	2	
H1036	060	1	01	01	01000					1		1		1		1010000100	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.Member can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$20 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	3		2				2						Copay amount depends on setting where service is received: $0 PCP $20 Specialist	2	
H1036	061	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	2		2				2							2	
H1036	062	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$10 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP$10 Specialist	2	
H1036	063	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	2		2				2							2	
H1036	065	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$10 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $10 Specialist	2	
H1036	066	1	01	01	01000							1		1		1010000000	1																																				2																2		2			2					2	Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$15 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $15 Specialist	2	
H1036	067	1	01	01	01000					1		1		1		1010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.Health Education/Wellness: Nutritional Supplement BenefitMember can receive up to a 90-day supply of selected nutritional supplements.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $0 PCP $25 Specialist	2	
H1036	068	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.                $5 PCP$35 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $35 Specialist	2	
H1036	801	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H1036	802	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H1036	803	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H1045	001	1	05	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2	01000	1	1	1			1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1076	003	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1076	010	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1076	011	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1076	012	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1076	013	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1076	016	1	01	01	00001		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		1	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1076	018	2	01	01	00001		2	2	2			2	2		2	0111110001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	If immunizations are done in a doctor's office any office visit copay may apply.	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1078	001	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health Education is for Diabetes only.	2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1078	002	2	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health education is only for diabetes.	2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1078	003	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health education is for diabetes only.	2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1078	007	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health education is for diabetes only.	2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1078	008	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health education is for diabetes only.	2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1078	009	1	01	01	01000			1	1			1				0110000001	1																																				2																2		2			2					2	Health education is only for diabetes.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1080	004	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	011	1	02	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	013	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	024	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	025	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	026	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	027	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	028	1	02	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1080	029	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H1099	001	1	01	01	01000			1		1		1				0010000101	1																																				2																2		2			2					2	We offer free Health Club Membership through the Silver Sneakers Program.	2	01000			2						2				2	1		2				2	Physician office visit copayment applies if service is performed during an office visit.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	00111	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H1099	006	1	01	01	01000			1		1		1				0010000101	1																																				2																2		2			2					2	We offer free Health Club Membership through the Silver Sneakers Program.	2	01000			2						2				2	3		2				2	Physician office visit copayment applies if service is performed during an office visit.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00010	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Physician office visit copayment applies if service is performed during an office visit.	2	
H1170	002	1	01	01	01000			2	2		2	2	2		2	0111100011	1																																				2				0.00	25.00	0.00	75.00			0.00	0.00	25.00			0.00	1		2			2					2		2	00100	1	2	1						2				2	1		2				2	Office visit copay may apply for Hepatitus B vaccine. Standard immunizations are covered. These may include but are not limited to: tetanus, measle/mumps/rubella, typhoid, varicella, and plague. The standard office visit copay may apply for standard immunizations.	2	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Office copayment of $35.00 applies if OB/GYN provider renders services, $25.00 copayment applies if Primary Care Provider renders service. No additional copayment for Pap Smear or Pelvic Exam.	2	
H1170	005	2	01	01	01000			2	2		2	2	2		2	0111100011	1																																				2				0.00	25.00	0.00	75.00			0.00	0.00	25.00			0.00	1		2			2					2		2	00100	1	2	1						2				2	1		2				2	Office visit copay may apply for Hepatitus B vaccine. Standard immunizations are covered. These may include but are not limited to: tetanus, measle/mumps/rubella, typhoid, varicella, and plague. The standard office visit copay may apply for standard immunizations.	2	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Office copayment of $35.00 applies if OB/GYN provider renders services, $25.00 copayment applies if Primary Care Provider renders service. No additional copayment for Pap Smear or Pelvic Exam.	2	
H1230	001	1	01	01	10000	1		1	1		1	1	1		1	0111101011	1																																				2	0.00	10.00		0.00	10.00	0.00	10.00			0.00	0.00	10.00			10.00	1		2			2					2	Fees for classes vary and are subject to change.Education in the appropriate use of Health Plan services and general health education publications distributed by Health Plan are provided without charge.General health education services are provided upon payment of a $10.00 Supplemental Charge per visit.  General health education services include patient education classes which are educational programs directed toward members who have specific diagnosed medical conditions whereby members are taught self-care skills to understand, monitor, manage and/or improve their condition.Specialized health promotion classes and support groups are not covered benefits.  When available, specialized health promotion classes and support groups are provided upon payment of reasonable charges.  Health promotion classes and support groups include educational programs directed to members who wish to make changes in their behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.With the exception of the Prenatal/Post Partum Exercise class, members may enroll in classes without a physician referral.  Enrollment in the class entitled Prenatal/Post Partum Exercise requires a referral from the member's treating physician.Exclusions and limitations apply.	2	00001	1	1	1	2	5	50	20	0	1				2	3		2				2	Members pay 50% of the non-Member rate for unexpected mass immunizations and immunizations developed or in general use after March 1, 1994.  When Medicare covers these types of immunizations, members may pay either no charge or 20% of Medicare approved charge for the immunization, whichever is applicable.Immunizations (in keeping with prevailing medical standards as defined by State law) for children 5 years and under are provided without charge.Injectable travel immunizations are provided upon payment of 50% of applicable charges.  Travel immunization office visits are provided upon payment of $10 office visit charge. Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.There is a maximum amount of copayments for Basic Health Services members pay during a calendar year.  The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the Evidence of Coverage.  Payment for travel immunizations and office visits for travel immunizations are not applicable toward the maximum enrollee-out-of-pocket amount.Exclusions and limitations apply.	1	01000	1	1	2	1	3	1			2		2	1		2				2					2	A $10.00 office visit charge applies.  Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.There is a maximum amount of copayments for Basic Health Services members pay during a calendar year. The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the EOC.Physical examinations and related services required by an outside agency/body such as, for obtaining or maintaining employment or participation in employee programs, insurance or licensing, or on court order or required for parole or probation are excluded from coverage.  This exclusion does not apply if a Medical Group Physician determines that the services are medically necessary.Exclusions and limitations apply.	2	01000										2									2					2	1		2				2						There is a maximum amount of copayments for Basic Health Services members pay during a calendar year. The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the EOC.If a Plan Physician decides that required covered services and supplies are not available from Kaiser Permanente, the physician may refer the member to a non-Plan provider inside or outside the service area.  The member must have a written referral to the non-Plan provider in order for KP to consider coverage for those services and supplies.A $10.00 office visit charge applies.Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.Exclusions and limitations apply.	2	
H1230	002	2	01	01	10000	1		1	1		1	1	1		1	0111101011	1																																				2	0.00	10.00		0.00	10.00	0.00	10.00			0.00	0.00	10.00			10.00	1		2			2					2	Fees for classes vary and are subject to change.Education in the appropriate use of Health Plan services and general health education publications distributed by Health Plan are provided without charge.General health education services are provided upon payment of a $10.00 Supplemental Charge per visit.  General health education services include patient education classes which are educational programs directed toward members who have specific diagnosed medical conditions whereby members are taught self-care skills to understand, monitor, manage and/or improve their condition.Specialized health promotion classes and support groups are not covered benefits.  When available, specialized health promotion classes and support groups are provided upon payment of reasonable charges.  Health promotion classes and support groups include educational programs directed to members who wish to make changes in their behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.With the exception of the Prenatal/Post Partum Exercise class, members may enroll in classes without a physician referral.  Enrollment in the class entitled Prenatal/Post Partum Exercise requires a referral from the member's treating physician.Exclusions and limitations apply.	2	00001	1	1	1	2	5	50	20	0	1				2	3		2				2	Members pay 50% of the non-Member rate for unexpected mass immunizations and immunizations developed or in general use after March 1, 1994.  When Medicare covers these types of immunizations, members may pay either no charge or 20% of Medicare approved charge for the immunization, whichever is applicable.Immunizations (in keeping with prevailing medical standards as defined by State law) for children 5 years and under are provided without charge.Injectable travel immunizations are provided upon payment of 50% of applicable charges.  Travel immunization office visits are provided upon payment of $10 office visit charge. Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.There is a maximum amount of copayments for Basic Health Services members pay during a calendar year.  The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the Evidence of Coverage.  Payment for travel immunizations and office visits for travel immunizations are not applicable toward the maximum enrollee-out-of-pocket amount.Exclusions and limitations apply.	1	01000	1	1	2	1	3	1			2		2	1		2				2					2	A $10.00 office visit charge applies.  Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.There is a maximum amount of copayments for Basic Health Services members pay during a calendar year. The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the EOC.Physical examinations and related services required by an outside agency/body such as, for obtaining or maintaining employment or participation in employee programs, insurance or licensing, or on court order or required for parole or probation are excluded from coverage.  This exclusion does not apply if a Medical Group Physician determines that the services are medically necessary.Exclusions and limitations apply.	2	01000										2									2					2	1		2				2						There is a maximum amount of copayments for Basic Health Services members pay during a calendar year. The member will have no obligation to pay for these services after the limit is met.  All payments are credited toward the calendar year in which the services were received.  Further detail is provided in the EOC.If a Plan Physician decides that required covered services and supplies are not available from Kaiser Permanente, the physician may refer the member to a non-Plan provider inside or outside the service area.  The member must have a written referral to the non-Plan provider in order for KP to consider coverage for those services and supplies.A $10.00 office visit charge applies.Members must pay a $25.00 office visit charge if the applicable $10 office visit charge is not paid at the time of the office visit.Exclusions and limitations apply.	2	
H1350	001	1	01	01	00111		2		2							0100010000	1																																				2																2		2			2					2	Cholesterol Management Classes are offered.	2	01000			2						2				2	3		2				2	Doctor office visit copayment may apply, ask your provider at the time of service.	2	00100	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						Doctor office visit copayment may apply, ask your provider at the time of service.	2	
H1350	802	1	01	01	00111		2		2							0100010000	1																																				2																2		2			2					2	Cholesterol Management Classes are offered.	2	01000			2						2				2	3		2				2	Doctor office visit copayment may apply, ask your provider at the time of service.	2	00100	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						Doctor office visit copayment may apply, ask your provider at the time of service.	2	
H1406	006	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $15 PCP $30 Specialist	2	
H1406	007	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$30 SPC	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $15 PCP $30 SPC	2	
H1406	013	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$0 PCP$30 Specialists	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	3		2				2						Copay amount depends on setting where service is received: $0 PCP $30 Specialists	2	
H1406	014	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$30 Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $15 PCP $30 Specialist	2	
H1406	801	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H1463	001	1	01	01	00110		2	2			2	2			2	0010110011	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	Office visit copayment will apply if immunizations are received in a physician's office. An exception to the office visit copayment is made for influenza and pneumonia vaccinations.	2	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	1		2				2					2	Office visit copayment will apply.	2	2
H1468	004	1	01	01	00101		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	10.00				0.00	10.00	0.00	10.00	0.00	1		2			2					2	Additional programs include diabetes awareness/wellness programs, pnuemoccal/flu shot education, colorectal screening awareness, mammography awareness, etc.  Scales are covered one time for CHF patients identified as appropriate through a disease management program.	1	01000	1	1	1						2	10.00	10.00	10.00	1	3		2				2	The only time a separate office visit cost share applies is if the immunization is secondary to a primary treatment for which the office visit occured.  Tetanus shots covered every 10 years or as medically indicated.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	00101		1	01		2		1		3	1									2					2	1		2				2					2		2	
H1804	001	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $15 PCP* $30 Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	002	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	003	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	004	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $15 PCP* $30 Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	005	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	006	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	007	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	008	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	009	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	010	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	011	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	012	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	013	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	014	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	015	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	016	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	017	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	018	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	019	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	020	1	09	04	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $15 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1804	801	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  All other covered vaccines, a copay may apply based on the setting where the service is received:* $20 PCP* $30 Specialist	2							2																				01000										2									2					2	1		2				2						Based on place of treatment, copays range as follows:* $20 PCP* $30 Specialist	2	
H1804	802	1	09	04	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  All other covered vaccines, a copay may apply based on the setting where the service is received:* $20 PCP* $30 Specialist	2							2																				01000										2									2					2	1		2				2						Based on place of treatment, copays range as follows:* $20 PCP* $30 Specialist	2	
H1849	005	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H1849	006	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H1849	009	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H1903	001	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2			0.00	5.00	5.00	0.00	0.00			0.00	0.00	0.00			0.00	1		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1951	001	1	01	01	01000				1	1			1		1	0101100100	1																																				2						10.00	10.00	0.00	0.00			10.00			10.00	1		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2	10.00	10.00			1	2		2				2							2	2
H1951	005	1	01	01	01000				1	1			1		1	0101100100	1																																				2						10.00	10.00	0.00	0.00			10.00			10.00	1		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2	10.00	10.00			1	2		2				2							2	2
H1951	006	1	02	01	01000				1	1			1		1	0101100100	1																																				2						5.00	5.00	0.00	0.00			5.00			5.00	1		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2	5.00	5.00			1	1		2				2							2	2
H1951	801	1	01	01	01000				1	1			1		1	0101100100	1						5	5			5		5											20			20	0		0			20		20		1						0.00	0.00	0.00	0.00			0.00			0.00	1		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	1		2				2		2							2																				01000										2	2	2			20	20			1					2	1		2				2							2	1
H1961	001	1	01	01	00101		1	1	1	1		1	1			0111010101	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Choice 1 benefit:  Member's care must be coordinated by his/her PCP and the covered service must be provided within the member's Independent Physician Asoociation (IPA).Choice 2 benefit:  Not covered.	2	00101	1	1	11	1	1					1									2	0.00	0.00	10.00	10.00	1	2		2				2					2		1	2
H2108	001	1	01	01													2																																																																	00001			2	4			20		1				2	1		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2	4	4			20	20			1					2	1		2				2						Members can self-refer to participating specialists without a referral.	2	1
H2108	002	1	01	01													2																																																																	00001			2	4			20		1				2	1		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2	4	4			20	20			1					2	1		2				2						Members can self-refer to participating specialists without a referral.	2	1
H2108	004	1	01	01													2																																																																	00001			2	4			20		1				2	1		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2	4	4			20	20			1					2	1		2				2						Members can self-refer to participating specialists without a referral.	2	1
H2108	005	1	01	01													2																																																																	00001			2	4			20		1				2	2		2				2		1	00001	1	1	1			1			2	15.00	1	2		2				2					2	You pay $15 per visit for routine physical exams performed by your PCP.	2	00001										2									2					2	1		2				2						Members can self-refer to participating specialists without a referral.  /The member copayment for a Medicare-covered pelvic exam is $20 if performed by a specialist and $15 if performed by a PCP.There is no copayment for each Medicare-coverd Pap Smear once every 2 years, annualy for beneficiaries at high risk.	2	
H2204	007	1	01	01													2																																																																	01000			2						2	0.00			1	3		2				2	Office visit copayment may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2	0.00	0.00	0.00	0.00	1	3		2				2					2	Office visit copayment may apply	2	2
H2206	003	1	01	01													2																																																																	01000			2						2	0.00			1	3		2				2	Office visit copayment may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2	0.00	0.00	0.00	0.00	1	3		2				2					2	Office visit copayment may apply	2	2
H2206	013	2	01	01													2																																																																	01000			2						2	0.00			1	3		2				2	Office visit copayment may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	2	2	1									2	0.00	0.00	0.00	0.00	1	3		2				2					2	Office visit copayment may apply.	2	2
H2256	001	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	002	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	005	2	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	006	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	008	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	009	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	010	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	012	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	013	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	014	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2256	801	1	01	01													2																																																																	00101			2						2				2	3		2				2	If other services are provided during the office visit, a copayment may apply.No referral necessary for network providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00101										2									2					2	3		2				2						If other servcies are provided during the office visit, the $15 copayment may apply,No referral is needed only for network providers.	2	
H2261	005	1	01	01	01000		2	2	2	2		2				0110010101	1																																				2																2		2			2					2	The plan offers a fitness benefit of $150 per calendar year for reimbursement of membership and/or fees in a health/fitness facility.The plan offers a weight loss benefit of $150 per calendar year toward fees paid for a Weight Watchers or hospital-based weight loss program.The plan offers a one time smoking cessation benefit of a 90 day supply for gum or patch, for which if prescription, a copay applies.A separate office visit copayment may apply if disease managment services are provided in a physician's office as part of an office visit.	2	01000	1	2	1						2				2	3		2				2	Immunizations for flu and pneumoncoccal pneumonia vaccinations are covered at no cost.  No referral or authorization is required and no separate office visit copayment is applied for the vaccination alone.Other routine immunizations, such as travel vaccinations and hepatitis B for members who are at risk are covered at no cost; a separate office visit copayment may apply.	2	01000	2	1	2	1	6	1			2	10.00	1	2		2				2					2	The number of visits for routine physicals is as determined appropriate by the Primary Care Physician.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	A $10 copayment applies for a PCP office visit associatedwith either a Pap Smear or pelvic examination.  A $20 copayment applies when the services are performed by a GYN or other women's health specialist.  There are no additional charges for lab servies related to routine screening.  A referal or authorization is not required.	2	
H2261	007	1	01	01	01000		2	2	2	2		2				0110010101	1																																				2																2		2			2					2	The plan offers a fitness benefit of $150 per calendar year for reimbursement of membership and/or fees in a health/fitness facility.The plan offers a weight loss benefit of $150 per calendar year toward fees paid for a Weight Watchers or hospital-based weight loss program.The plan offers a one time smoking cessation benefit of a 90 day supply for gum or patch, for which if prescription, a copay applies.A separate office visit copayment may apply if disease managment services are provided in a physician's office as part of an office visit.	2	01000	1	2	1						2				2	3		2				2	Immunizations for flu and pneumoncoccal pneumonia vaccinations are covered at no cost.  No referral or authorization is required and no separate office visit copayment is applied for the vaccination alone.Other routine immunizations, such as travel vaccinations and hepatitis B for members who are at risk are covered at no cost; a separate office visit copayment may apply.	2	01000	2	1	2	1	6	1			2	10.00	1	2		2				2					2	The number of visits for routine physicals is as determined appropriate by the Primary Care Physician.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	A $10 copayment applies for a PCP office visit associatedwith either a Pap Smear or pelvic examination.  A $20 copayment applies when the services are performed by a GYN or other women's health specialist.  There are no additional charges for lab servies related to routine screening.  A referal or authorization is not required.	2	
H2261	008	1	01	01	01000		2	2	2	2		2				0110010101	1																																				2																2		2			2					2	The plan offers a fitness benefit of $150 per calendar year for reimbursement of membership and/or fees in a health/fitness facility.The plan offers a weight loss benefit of $150 per calendar year toward fees paid for a Weight Watchers or hospital-based weight loss program.The plan offers a one time smoking cessation benefit of a 90 day supply for gum or patch, for which if prescription, a copay applies.A separate office visit copayment may apply if disease managment services are provided in a physician's office as part of an office visit.	2	01000	1	2	1						2				2	3		2				2	Immunizations for flu and pneumoncoccal pneumonia vaccinations are covered at no cost.  No referral or authorization is required and no separate office visit copayment is applied for the vaccination alone.Other routine immunizations, such as travel vaccinations and hepatitis B for members who are at risk are covered at no cost; a separate office visit copayment may apply.	2	01000	2	1	2	1	6	1			2	10.00	1	2		2				2					2	The number of visits for routine physicals is as determined appropriate by the Primary Care Physician.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	A $10 copayment applies for a PCP office visit associatedwith either a Pap Smear or pelvic examination.  A $20 copayment applies when the services are performed by a GYN or other women's health specialist.  There are no additional charges for lab servies related to routine screening.  A referal or authorization is not required.	2	
H2261	009	1	01	01	01000		2	2	2	2		2				0110010101	1																																				2																2		2			2					2	The plan offers a fitness benefit of $150 per calendar year for reimbursement of membership and/or fees in a health/fitness facility.The plan offers a weight loss benefit of $150 per calendar year toward fees paid for a Weight Watchers or hospital-based weight loss program.The plan offers a one time smoking cessation benefit of a 90 day supply for gum or patch, for which if prescription, a copay applies.A separate office visit copayment may apply if disease managment services are provided in a physician's office as part of an office visit.	2	01000	1	2	1						2				2	3		2				2	Immunizations for flu and pneumoncoccal pneumonia vaccinations are covered at no cost.  No referral or authorization is required and no separate office visit copayment is applied for the vaccination alone.Other routine immunizations, such as travel vaccinations and hepatitis B for members who are at risk are covered at no cost; a separate office visit copayment may apply.	2	01000	2	1	2	1	6	1			2	10.00	1	2		2				2					2	The number of visits for routine physicals is as determined appropriate by the Primary Care Physician.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	A $10 copayment applies for a PCP office visit associatedwith either a Pap Smear or pelvic examination.  A $20 copayment applies when the services are performed by a GYN or other women's health specialist.  There are no additional charges for lab servies related to routine screening.  A referal or authorization is not required.	2	
H2261	010	1	01	01	01000		2	2	2	2		2				0110010101	1																																				2																2		2			2					2	The plan offers a fitness benefit of $150 per calendar year for reimbursement of membership and/or fees in a health/fitness facility.The plan offers a weight loss benefit of $150 per calendar year toward fees paid for a Weight Watchers or hospital-based weight loss program.The plan offers a one time smoking cessation benefit of a 90 day supply for gum or patch, for which if prescription, a copay applies.A separate office visit copayment may apply if disease managment services are provided in a physician's office as part of an office visit.	2	01000	1	2	1						2				2	3		2				2	Immunizations for flu and pneumoncoccal pneumonia vaccinations are covered at no cost.  No referral or authorization is required and no separate office visit copayment is applied for the vaccination alone.Other routine immunizations, such as travel vaccinations and hepatitis B for members who are at risk are covered at no cost; a separate office visit copayment may apply.	2	01000	2	1	2	1	6	1			2	10.00	1	2		2				2					2	The number of visits for routine physicals is as determined appropriate by the Primary Care Physician.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	A $10 copayment applies for a PCP office visit associatedwith either a Pap Smear or pelvic examination.  A $20 copayment applies when the services are performed by a GYN or other women's health specialist.  There are no additional charges for lab servies related to routine screening.  A referal or authorization is not required.	2	
H2312	004	1	01	01	00101		1	1	1				1		1	0101110001	1																																				2																2		2			2					2		1	00111	1	1	1						2				2	1		2				2	HAP covers immunizations ordered by an Affiliated Provider as medically necessary.  HAP does not provide coverage for immunizations necessary for foreign travel.	1	01000	1	1	1			1			2		2	1		2				2					2		2	01000	1	1	11	1	1					1									2					2	1		2				2					2		2	
H2354	001	1	01	01	01000		2	2	2			2			2	0110110001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	A doctor office visit copayment of $10.00 may applyNo referral necessary for in-plan providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	No referral necessary for in-plan provider.	2	01000										2									2					2	3		2				2						No referral necessary for in-plan provider.A separate office visit copay of $10.00 may apply.	2	
H2354	007	1	01	01	01000		2	2	2			2			2	0110110001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	A doctor office visit copayment of $7.00 may applyNo referral necessary for in-plan providers.	2	01000	2	1	2	1	3	1			2	7.00	1	2		2				2					2	No referral necessary for in-plan provider.	2	01000										2									2					2	3		2				2						No referral necessary for in-plan provider.A separate office visit copay of $7.00 may apply.	2	
H2354	008	1	01	01	01000		2	2	2			2			2	0110110001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	A doctor office visit copayment of $10.00 may applyNo referral necessary for in-plan providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	No referral necessary for in-plan provider.	2	01000										2									2					2	3		2				2						No referral necessary for in-plan provider.A separate office visit copay of $10.00 may apply.	2	
H2354	009	1	01	01	01000		2	2	2			2			2	0110110001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	A doctor office visit copayment of $7.00 may applyNo referral necessary for in-plan providers.	2	01000	2	1	2	1	3	1			2	7.00	1	2		2				2					2	No referral necessary for in-plan provider.	2	01000										2									2					2	3		2				2						No referral necessary for in-plan provider.A separate office visit copay of $7.00 may apply.	2	
H2354	012	1	01	01	01000		2	2	2			2			2	0110110001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	A doctor office visit copayment of $10.00 may applyNo referral necessary for in-plan providers.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	No referral necessary for in-plan provider.	2	01000										2									2					2	3		2				2						No referral necessary for in-plan provider.A separate office visit copay of $10.00 may apply.	2	
H2406	001	1	04	01													2																																																															Evercare offers the following benefits within the nursing home: Physician visits & Nurse Practitioner visits in a nursing home. Family Counsels in a nursing home.		10001	1	1	1						2				2	3		2				2	Primary Care Team: Nurse Practitioner and Primary Care PhysicianCopayment is $0 if services are provided an institutional setting but Office Visit copayment may apply.No copayment for Influenza and Pneumococcal vaccinations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Copayment is $0 if services are provided an institutional setting.  $10 copayment if services are provided by a participating provider in a non-institutional facility.Primary Care Team: Nurse Practitioner and Primary Care Physician	1	00100										2									2					2	3		2				2						Primary Care Team: Nurse Practitioner and Primary Care PhysicianEnrollees maybe charged copayment / coinsurance depending on services received and place of service.Copayment is $0 if services are provided an institutional setting. $25 copayment if services are provided by a participating specialist in a non-institutional facility.	1	
H2408	001	1	09	04	01000			1			1	1		1		1010000011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2408	002	1	09	04	01000			1			1	1		1		1010000011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2408	003	1	09	04	01000			1			1	1		1		1010000011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2408	004	1	09	04	01000			1			1	1		1		1010000011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2459	001	1	02	01	01000		1	1	1		1	1			1	0110110011	1																																				2																2		2			2					2	Your PCC will need to authorize enrollment into the CHF or any other disease management program.	2	10100	1	1	1						2				2	2		2				2	Pneumococcal vaccinations, immunizations required because of an injury or immediate risk of infection, hepatits B vaccine for members considered to be at high or immediate risk of contracting the disease, and influenza virus vaccines.UCare also covers immunizations for Lyme disease, Hepatitis A, and Diphtheria and tenanus toxoids (CPT codes 90632, 90665, and 90702).Authorization not needed unless service is received from a non-par md, except for pneumococcal or flu vaccines.	2	10000	1	1	2	1	3	1			2		2	2		2				2					2	No auth needed if services received from PCC.	2	10000		1	01		2		1		3	1									2					2	2		2				2					2	No copayment for one pap smear annually for women over 40 years of age.No auth needed if services received from PCC.	2	
H2459	002	1	02	01	01000		1	1	1		1	1			1	0110110011	1																																				2																2		2			2					2	Your PCC will need to authorize enrollment into the CHF or any other disease management program.	2	10000	1	1	1						2				2	2		2				2	Pneumococcal vaccinations, immunizations required because of an injury or immediate risk of infection, hepatits B vaccine for members considered to be at high or immediate risk of contracting the disease, and influenza virus vaccines.UCare also covers immunizations for Lyme disease, Hepatitis A, and Diphtheria and tenanus toxoids (CPT codes 90632, 90665, and 90702).Authorization not needed unless service is received from a non-par md, except for pneumococcal or flu vaccines.	2	10000	1	1	2	1	3	1			2		2	2		2				2					2	No auth needed if services received from PCC.	2	10000		1	01		2		1		3	1									2					2	2		2				2					2	No copayment for one pap smear annually for women over 40 years of age.No auth needed if services received from PCC.	2	
H2610	001	1	01	01													2																																																																	01000			2						2				2	2		2				2		1	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							1	
H2649	004	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$10 PCP$35 SPC	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Copay amount depends on setting where service is received: $10 PCP $35 Specialist	2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $10 PCP $35 Specialist	2	
H2649	011	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$20 PCP$35 Specialist	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2	Copay amount depends on setting where service is received: $20 PCP $35 Specialist	2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $20 PCP $35 Specialist	2	
H2649	012	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00111										2									2					2	2		2				2							2	
H2649	801	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H2649	805	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H2654	004	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	005	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	010	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	013	1	02	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	014	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	015	1	02	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	016	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	017	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	018	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2654	019	1	02	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2663	002	1	01	01	00100									1		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	2	00100			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00100										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H2663	003	2	01	01	00100									2		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	2	00100			2						2				2	2		2				2		2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00100										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H2663	005	1	01	01	00100									1		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	1	00100			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00100										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H2663	801	1	01	01	00100									2		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	2	00100			2						2				2	2		2				2		2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00100										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H2667	001	1	01	01	00110		2	2	2		2	2	2		2	0111110011	1																																				2			25.00	25.00	25.00	10.00	10.00			0.00	0.00	10.00			10.00	1		2			2					2	Copays are charged per session.You may be referred by a PCP or Specialist.	1	00110	1	2	1						2	0.00	0.00	15.00	1	3		2				2	Office copay may apply if performed in physician's office.	1	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2	$30 copay if performed in the Specialist office.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	3		2				2					2	Office copay may apply if performed in physician's office.Referral necessary for exams above and beyond the annual visit.	1	
H2667	003	1	01	01	10000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Copays are charged per session.You may be referred by a PCP, Specialist or Medical Management.	2	10000	1	2	1						2	0.00	0.00	15.00	1	3		2				2	Office copay may apply if performed in physician's office.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2	$25 copay if performed in the Specialist office.	2	00110	2	2	11	2	2	1	1	2	2	1									2	0.00	0.00	0.00	0.00	1	3		2				2					2	Office copay may apply if performed in physician's office.	2	2
H2667	005	1	01	01	10000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Copays are charged per session.You may be referred by a PCP, Specialist or Medical Management.	2	10000	1	2	1						2	0.00	0.00	15.00	1	3		2				2	Office copay may apply if performed in physician's office.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2	$25 copay if performed in the Specialist office.	2	00110	2	2	11	2	2	1	1	2	2	1									2	0.00	0.00	0.00	0.00	1	3		2				2					2	Office copay may apply if performed in physician's office.	2	2
H2672	001	1	01	01	00001		1	1	1		1	1				0110010011	1																																				2																2		2			2					2	The plan covers a variety of services.  Ask Advantra for more details.Members Choice (SM) offers access to a wide variety of complementary services to help members lead a healthier lifestyle.  The program is offered through a relationship with American Specialty Health Networks (ASHN) and Healthyroads.	2	01000	1	1	1						2				2	3		2				2	Office visit copayment may apply.$0 copayment for Pneumococcal pneumonia vaccine and flu vaccines.$0 copayment for Hepatitis B vaccineFor flu shots and pneumonia vaccines, you can self-refer to a network provider.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	$30 copayment may apply when services are performed by a specialist.	2	01000		1	01		2		1		3	1									2					2	3		2				2					2	No referral necessary for network providers.Doctor office visit copayment may apply when you are treated for illnesses that are not related to your preventive care during the same visit.	2	
H2672	002	1	01	01	00001		1	1	1		1	1				0110010011	1																																				2																2		2			2					2	The plan covers a variety of services.  Ask Advantra for more details.Members Choice (SM) offers access to a wide variety of complementary services to help members lead a healthier lifestyle.  The program is offered through a relationship with American Specialty Health Networks (ASHN) and Healthyroads.	2	01000	1	1	1						2				2	3		2				2	Office visit copayment may apply.$0 copayment for Pneumococcal pneumonia vaccine and flu vaccines.$0 copayment for Hepatitis B vaccineFor flu shots and pneumonia vaccines, you can self-refer to a network provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	$25.00 copayment may apply when services are performed by a specialist.	2	01000		1	01		2		1		3	1									2					2	3		2				2					2	No referral necessary for network providers.Doctor office visit copayment may apply when you are treated for illnesses that are not related to your preventive care during the same visit.	2	
H2672	801	1	01	01	00001		1	1	1		1	1				0110010011	1																																				2																2		2			2					2	The plan covers a variety of services.  Ask Advantra for more details.Members Choice (SM) offers access to a wide variety of complementary services to help members lead a healthier lifestyle.  The program is offered through a relationship with American Specialty Health Networks (ASHN) and Healthyroads.	2	01000	1	1	1						2				2	3		2				2	Office visit copayment may apply.$0 copayment for Pneumococcal pneumonia vaccine and flu vaccines.$0 copayment for Hepatitis B vaccineFor flu shots and pneumonia vaccines, you can self-refer to a network provider.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	$30 copayment may apply when services are performed by a specialist.	2	01000		1	01		2		1		3	1									2					2	3		2				2					2	No referral necessary for network providers.Doctor office visit copayment may apply when you are treated for illnesses that are not related to your preventive care during the same visit.	2	
H2802	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2802	003	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2803	001	1	04	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit - $15 in network or out-of-network.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  No copayment, either in or out of network.  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2803	002	1	04	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  No copayment, either in or out of network.  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2803	003	1	04	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit - $15 in network or out-of-network.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  No copayment, either in or out of network.  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2803	004	1	04	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  No copayment, either in or out of network.  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H2931	002	1	02	01	01000		1	1	1	1	1	1	1		1	0111110111	1																																				2			5.00	5.00	20.00	5.00	35.00	0.00	0.00	0.00	0.00	5.00			25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances).  Enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  Individual nutrition educational consultations are available as necessary for a $5 copayment.There is a 50% for smoking cessation drugs up to one prescription each month of treatment for one three-month course of treatment per calendar year.	2	00111			2						2				2	3		2				2	No referral is required for network physician.   A doctor office visit and/or professional service copayment may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	No referral is required for network providers.  A doctor office visit and/or professional service copayment may apply as appropriate.	2	
H2931	004	1	01	01	01000						1	1				0010000010	1																																				2										0.00	0.00					1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances); enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  There is a 50% coinsurance for smoking cessation drugs up to one prescription each month of treatment and one three-month course of treatment per calendar year.	2	00111			2	1			20		1				2	3		2				2	No referral is required for network physician.  Hepatitis vaccinations require a 20% coinsurance and are covered at Medicare's approved amount.Copayments/coinsurance for professional services and/or ancillary services may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1	1	1	1	1	20	20	20	20	1					2	3		2				2					2	No referral is required for network providers.	2	2
H2931	006	1	01	01	01000				1	1	1	1			1	0110100110	1																																				2						5.00	35.00	0.00	0.00	0.00	0.00				25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances); enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  There is a 50% coinsurance for smoking cessation drugs up to one prescription each month of treatment and one three-month course of treatment per calendar year.	2	00111			2	1			20		1				2	3		2				2	No referral is required for network physician.  Hepatitis vaccinations require a 20% coinsurance and are covered at Medicare's approved amount.Copayments/coinsurance for professional services and/or ancillary services may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1	1	1	1	1	20	20	20	20	1					2	3		2				2					2	No referral is required for network providers.	2	2
H2931	008	2	01	01	01000		1	1	1	1	1	1	1		1	0111110111	1																																				2			5.00	5.00	20.00	5.00	35.00	0.00	0.00	0.00	0.00	5.00			25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances).  Enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  Individual nutrition educational consultations are available as necessary for a $5 copayment.There is a 50% for smoking cessation drugs up to one prescription each month of treatment for one three-month course of treatment per calendar year.	2	00111			2						2				2	3		2				2	No referral is required for network physician.   A doctor office visit and/or professional service copayment may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	No referral is required for network providers.  A doctor office visit and/or professional service copayment may apply as appropriate.	2	
H2931	801	1	01	01	01000		1	1	1	1	1	1	1		1	0111110111	1																																				2			5.00	5.00	20.00	5.00	35.00	0.00	0.00	0.00	0.00	5.00			25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances).  Enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  Individual nutrition educational consultations are available as necessary for a $5 copayment for members in Southern Nevada.There is a 50% for smoking cessation drugs up to one prescription each month of treatment for one three-month course of treatment per calendar year.	2	00111			2						2				2	3		2				2	No referral is required for network physician.   A doctor office visit and/or professional service copayment may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	No referral is required for network providers.  A doctor office visit and/or professional service copayment may apply as appropriate.	2	
H2949	002	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers enrollment fee and dues for 24 Hour Fitness health club program.	2	00100			2						2	0.00			1	1		2				2		1	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2							2	2
H2949	005	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H2949	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H2960	004	1	02	01	00001		1	1	1		1	1			1	0110110011	1																																				2																2		2			2					2		1	01000			2	2			20		1				2	1		2				2		2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	1	1	11	1	1					1									2					2	1		2				2					2		2	
H3107	001	1	01	01	01000		1	1	1		1	1				0110010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3107	004	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3107	005	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3107	006	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3112	001	1	01	01	10000			1	1	1		1	1	1	1	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Cardiac Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply. Not covered for travel.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.	2	2
H3152	022	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3152	029	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3152	037	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3152	801	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3152	803	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3154	003	1	01	01	01000						2					0000000010	1																																				2																2		2			2					2	Physician office visit copay applies.	2	01000			2						2	10.00			1	3		2				2	Enrollees pay nothing for flu and pneumococcal immunizations; however, a copay for the office visit will apply if the enrollee receives other services at the time of the immunizaiton.  You do not need a referral for influena and pneumococcal immunizations but one is required for other immunizations.pneumococcal and flu vacine covered in full.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3156	021	1	01	01	10000			2	2	2			2	2	2	1101100101	1																																				2																2		2			2					2	#14a, Health Ed/Wellness:Weight Management: Reimbursement capped at $200 per 365 day period for plan approved weight management programs.  Some retrictions apply.  Fitness Reimbursement:  Up to $150 reimbursement upon completion of 120 visits within a 365 day period.  Some restrictions apply.Smoking Cessation:  Up to a $200 maximum reimbursement upon completion of Smoking Cessation program.  Some restrictions apply.Disease Management: Asthma, Cardiac, Conjestive Heart Failure, Diabetes Management and Cardiac Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services:  If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	25.00	0.00	25.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services.  If there is a separate and distinct office visit evaluation and service , a copay may apply.	2	2
H3156	801	1	01	01	10000			2	2	2			2	2	2	1101100101	1																																				2																2		2			2					2	#14a, Health Ed/Wellness:Weight Management: Reimbursement capped at $200 per 365 day period for plan approved weight management programs.  Some retrictions apply.  Fitness Reimbursement:  Up to $150 reimbursement upon completion of 120 visits within a 365 day period.  Some restrictions apply.Smoking Cessation:  Up to a $200 maximum reimbursement upon completion of Smoking Cessation program.  Some restrictions apply.Disease Management: Asthma, Cardiac, Conjestive Heart Failure, Diabetes Management and Cardiac Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services:  If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	25.00	0.00	25.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services.  If there is a separate and distinct office visit evaluation and service , a copay may apply.	2	2
H3164	003	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	1		2			2					2	AmeriChoice also provides tele-medicine benefit to members.Please call Plan for details.	2	01000			2						2	0.00			1	3		2				2	Office visit copay may apply.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office visit copay may apply.	2	2
H3204	001	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	Some fees may apply for specific classes.	2	01000			2						2	0.00			1	1		2				2	Separate office visit copayment may apply if visit is in addition to immunization.  Immunizations must be received through network practitioners.	2	01000	1	1	2	1	3	1			2	0.00	1	2		2				2					2	Limited to 1 routine physical exam every calendar year.	2	01000										2									2	0.00	0.00			1	2		2				2						Limited to 1 exam every calendar year.	2	2
H3204	004	2	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	Some fees may apply for specific classes.	2	01000			2						2	0.00			1	1		2				2	Separate office visit copayment may apply if visit is in addition to immunization.  Immunizations must be received through network practitioners.	2	01000	1	1	2	1	3	1			2	0.00	1	2		2				2					2	Limited to 1 routine physical exam every calendar year.	2	01000										2									2	0.00	0.00			1	2		2				2						Limited to 1 exam every calendar year.	2	2
H3204	006	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	Some fees may apply for specific classes.	2	01000			2						2	0.00			1	1		2				2	Separate office visit copayment may apply if visit is in addition to immunization.  Immunizations must be received through network practitioners.	2	01000	1	1	2	1	3	1			2	0.00	1	2		2				2					2	Limited to 1 routine physical exam every calendar year.	2	01000										2									2	0.00	0.00			1	2		2				2						Limited to 1 exam every calendar year.	2	2
H3204	801	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	Some fees may apply for specific classes.	2	01000			2						2	0.00			1	1		2				2	Separate office visit copayment may apply if visit is in addition to immunization.  Immunizations must be received through network practitioners.	2	01000	1	1	2	1	3	1			2	0.00	1	2		2				2					2	Limited to 1 routine physical exam every calendar year.	2	01000										2									2	0.00	0.00			1	2		2				2						Limited to 1 exam every calendar year.	2	2
H3251	002	1	01	01	10000				1			1	1	1	1	1111100000	1																																				2						0.00	75.00				0.00	20.00	0.00	75.00	75.00	1		2			2					2	Some Fees for some health and wellness classes may apply.  A Health Information Line is offered.	2	00111			2						2				2	3		2				2	Doctor office visit copay may apply for immunizations received. Travel Immunization are not covered. Prior Authorization is required for immunization other than flu and pneum.	2	00111	1	1	2	1	3	1			2		2	2		2				2					2	Routine physical is covered once every calendar year.	2	00111										2									2					2	2		2				2							2	
H3251	018	1	01	01	01000				1			1	1	1	1	1111100000	1																																				2						0.00	75.00				0.00	20.00	0.00	75.00	75.00	1		2			2					2	Some Fees for some health and wellness classes may apply.  Health Information Line offered.	2	00111			2						2				2	3		2				2	Doctor office visit copay may apply for immunizations received.	1	00111	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Routine physical covered once every calendar year.	2	00111										2									2					2	2		2				2							2	
H3305	001	1	01	01	01000		2	2	2			2	2		2	0111110001	1																																				2																2		2			2	40.00	7		3	1	Health and Wellness:  Preferred Care Gold pays up to $40 toward the tuition for selected classes and programs that are designated to help you get-and-stay healthy, fit and well.  Classes include programs such as:Weight management:Weight WatchersThink Light Lowfat Living PlanExercise classes:Water and low-back exercise classesGeneral education:First aidCPRYou pay $0 for You're in Charge! classes such as:Living a Healthy Life With a Chronic ConditionSafe SteppingFall Prevention WorkshopFood, Fluid and FeelingsAddressing Nutritional Needs to Help Manage Congestive Heart FailureMedicine Bag ReviewYou're in Charge now includes Silver Sneakers who will be providing even more excercise classes throughout the communities and free fitness center memberships at participating providers.	2	00100	1	2	1						2				2	1		2				2	Precerticiation is required for a meningiococcal vaccine, hepatitis A and A & B combinations.Doctor office visit copayment may apply.	1	01000	2	1	2	1	3	1			2	10.00	1	1		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	10.00	0.00	10.00	1	1		2				2					2		2	2
H3305	007	1	01	01	01000		2	2	2			2	2		2	0111110001	1																																				2																2		2			2	40.00	7		3	1	Health and Wellness:  Preferred Care GoldValue pays up to $40 toward the tuition for selected classes and programs that are designated to help you get-and-stay healthy, fit and well.  Classes include programs such as:Weight management:Weight WatchersThink Light Lowfat Living PlanExercise classes:Water and low-back exercise classesGeneral education:First aidCPRYou pay $0 for You're in Charge! classes such as:Living a Healthy Life With a Chronic ConditionSafe SteppingFall Prevention WorkshopFood, Fluid and FeelingsAddressing Nutritional Needs to Help Manage Congestive Heart FailureMedicine Bag ReviewYou're in Charge now includes Silver Sneakers who will be providing even more excercise classes throughout the communities and free fitness center memberships at participating providers.	2	00100	1	2	1						2				2	1		2				2	Precerticiation is required for a meningiococcal vaccine, hepatitis A and A & B combinations.Doctor office visit copayment may apply.	1	01000	2	1	2	1	3	1			2	15.00	1	1		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	1		2				2					2		2	2
H3305	801	1	01	01	01000		2	2	2			2	2		2	0111110001	1																																				2																2		2			2	40.00	7		3	1	Health and Wellness:  Preferred Care Gold pays up to $40 toward the tuition for selected classes and programs that are designated to help you get-and-stay healthy, fit and well.  Classes include programs such as:Weight management:Weight WatchersThink Light Lowfat Living PlanExercise classes:Water and low-back exercise classesGeneral education:First aidCPRYou pay $0 for You're in Charge! classes such as:Living a Healthy Life With a Chronic ConditionSafe SteppingFall Prevention WorkshopFood, Fluid and FeelingsAddressing Nutritional Needs to Help Manage Congestive Heart FailureMedicine Bag ReviewYou're in Charge now includes Silver Sneakers who will be providing even more excercise classes throughout the communities and free fitness center memberships at participating providers.	2	00100	1	2	1						2				2	1		2				2	Precerticiation is required for a meningiococcal vaccine, hepatitis A and A & B combinations.Doctor office visit copayment may apply.	1	01000	2	1	2	1	3	1			2	10.00	1	1		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	10.00	0.00	10.00	1	1		2				2					2		2	2
H3307	002	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $15 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3307	004	1	02	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3307	008	2	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3307	010	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP.  You may be charged a copayment if you have a separate office visit in addition to the pap/pelvic exam.	2	
H3307	011	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $25 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3307	012	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3307	013	1	01	01	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations - Additional Coverage and Copayments.  We also cover Hepatitis B and lyme disease vaccines as frequently as necessary at the discretion of the PCP.  You may be charged a copayment if you have a separate office visit in addition to the immunization.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Section B - #14c Routine Phys - Benefit Description.  Oxford covers one routine physical at no charge every 12 months.  Any additional routine physical visits will not be covered by Oxford.  This is not a calendar year benefit, but a rolling 12 month benefit.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B - #14d Pap/Pelvic, Coverage and Copayment.  Women may visit an Oxford gynecologist at any time, without a referral from their PCP. A copayment of $10 is required for each visit, except for the annual no copayment examination.  You may be charged a copayment if you have a separate office visit in addition to the pap smear and pelvic exam.	2	
H3312	002	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	018	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	025	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	026	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	027	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	801	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3312	803	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3328	001	1	01	01	00001		1	1				1	1			0011010001	1																																				2																2		2			2					2	Prior Authorization is Required	1	00100			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	An Enrollee is entitled to one Routine Physical Exam a year performed by their PCP	2	00100		1	01		2		1		3	1									2					2	1		2				2					2	PCP Referral is Required for Additional Pap Smears and Pelvic Exams	1	
H3330	003	1	01	01	01000	1		1	1			1	1		1	0111101001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	00001										2									2					2	2		2				2							1	
H3330	004	1	01	01	01000	2			2			2	2		2	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	005	1	01	01	01000	2			2			2	2		2	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	006	1	01	01	01000	1			1			1	1		1	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	1		2				2							2	
H3330	007	1	01	01	01000	2			2			2	2		2	0111101000	1																																				2																2		2			2					2		2	00001			2						2				2	2		2				2		1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	008	1	01	01	01000	2			2			2	2		2	0111101000	1																																				2																2		2			2					2		2	00001			2						2				2	2		2				2		1	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	009	1	01	01	01000	1			1			1	1		1	0111101000	1																																				2																2		2			2					2		2	00001			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	010	1	01	01	01000	1			1			1	1		1	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	011	2	01	01	01000	1			1			1	1		1	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							1	
H3330	020	1	01	01	01000	1			1			1	1		1	0111101000	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3330	801	1	01	01													2																																																																	00001			2	4			20		1				2	2		2				2		1							2																				00001										2	4	4			20	20			1					2	2		2				2							2	2
H3333	001	1	09	04	01000				2							0100000000	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	1		2				2	Immunizations includes flu vaccine and pneumococcal vaccine	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	1		2				2							2	
H3333	002	1	09	04	01000				2							0100000000	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	1		2				2	Immunizations includes flu vaccine and pneumococcal vaccine	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	1		2				2							2	
H3333	003	1	09	04	01000				2							0100000000	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	1		2				2	Immunizations includes flu vaccine and pneumococcal vaccine	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	1		2				2							2	
H3333	004	1	09	04	01000				2							0100000000	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	1		2				2	Immunizations includes flu vaccine and pneumococcal vaccine	2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000										2									2					2	1		2				2							2	
H3335	002	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When Influenza, Pneumococcal and Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.   Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	10.00	1	2		2				2					2	This service may require a $10 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes).	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	003	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply. Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copay may apply.	2	
H3335	004	1	04	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	3		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	1	1	2	1	3	1	2	15	1	7.00	1	2		2				2					2	The copayment for an annual physical is $7 for E & M codes. All other services carry a 15% coinsurance.	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	005	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When influenza, pneumococcal and hepatitas B immunizations are administered during an office visit, the office visit copayment may apply. M Medicare covered  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	5.00	1	2		2				2					2	This service may require a $5 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes.)	2	01000										2									2					2	3		2				2						When performed during an office visit, an office visit copay may apply.	2	
H3335	006	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pnuemococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When preformed during an office visit, a $10 PCP office visit copayment may apply.	2	
H3335	007	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	15	1	7.00	1	2		2				2					2	The copayment for an annual physical is $7 for E & M codes. All other services carry a 15% coinsurance.	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	008	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When influenza, pneumococcal and hepatitas B immunizations are administered during an office visit, the office visit copayment may apply. M Medicare covered  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	5.00	1	2		2				2					2	This service may require a $5 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes.)	2	01000										2									2					2	3		2				2						When performed during an office visit, an office visit copay may apply.	2	
H3335	009	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pnuemococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When preformed during an office visit, a $10 PCP office visit copayment may apply.	2	
H3335	010	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	15	1	7.00	1	2		2				2					2	The copayment for an annual physical is $7 for E & M codes. All other services carry a 15% coinsurance.	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	011	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When influenza, pneumococcal and hepatitas B immunizations are administered during an office visit, the office visit copayment may apply. M Medicare covered  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	5.00	1	2		2				2					2	This service may require a $5 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes.)	2	01000										2									2					2	3		2				2						When performed during an office visit, an office visit copay may apply.	2	
H3335	012	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pnuemococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When preformed during an office visit, a $10 PCP office visit copayment may apply.	2	
H3335	013	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	15	1	7.00	1	2		2				2					2	The copayment for an annual physical is $7 for E & M codes. All other services carry a 15% coinsurance.	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	014	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When influenza, pneumococcal and hepatitas B immunizations are administered during an office visit, the office visit copayment may apply. M Medicare covered  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	5.00	1	2		2				2					2	This service may require a $5 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes.)	2	01000										2									2					2	3		2				2						When performed during an office visit, an office visit copay may apply.	2	
H3335	015	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pnuemococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When preformed during an office visit, a $10 PCP office visit copayment may apply.	2	
H3335	016	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	When Influenza, Pneumococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	15	1	7.00	1	2		2				2					2	The copayment for an annual physical is $7 for E & M codes. All other services carry a 15% coinsurance.	2	01000										2									2					2	3		2				2						When performed during an office visit, the office visit copayment may apply.	2	
H3335	017	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	When influenza, pneumococcal and hepatitas B immunizations are administered during an office visit, the office visit copayment may apply. M Medicare covered  Immunizations administered out of network have a 35% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1	2	10	1	5.00	1	2		2				2					2	This service may require a $5 copayment (for E&M codes only) and/or 10% coinsurance (for non-E&M codes.)	2	01000										2									2					2	3		2				2						When performed during an office visit, an office visit copay may apply.	2	
H3335	018	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When Influenza, Pnuemococcal or Hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Immunizations administered out of network have a 25% coinsurance after the annual $250 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When preformed during an office visit, a $10 PCP office visit copayment may apply.	2	
H3335	801	1	04	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3335	802	1	04	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3335	803	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3335	804	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3335	805	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3335	806	1	04	01	01000		2	2				2	2			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2	When influenza, pneumococcal or hepatitis B immunizations are administered during an office visit, the office visit copayment may apply.  Medicare covered  Immunizations administered out of network have a 40% coinsurance after the annual $1000 deductible has been met.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						When performed during an office visit, the $10 PCP office visit copayment may apply.	2	
H3351	001	1	01	01	10000		2	2				2	2			0011010001	1																																				2																2		2			2					2	Disease management and congestive heart program may require referral.	1	01000			2						2				2	3		2				2	There is no copayment for immunizations. if done in conjunction with an office visit a $5 office visit copayment will apply.	2	01000	2	1	1			1			2	5.00	1	2		2				2					2	There is no copayment for Routine Physicals. if done in conjunction with an office visit, a $5 office visit copayment will apply.	2	00110										2									2	5.00	5.00			1	1		2				2						If the PAP/Pelvic exam is done in conjunction with an office visit, there is no charge fo rthe PAP/Pelvic exam. You pay a $5. copayment for each office visit and/or consultation per provider per day.	2	2
H3351	002	1	01	01	10000		2	2				2	2			0011010001	1																																				2																2		2			2					2	Disease management and congestive heart program may require referral.	1	01000			2						2				2	3		2				2	Immunizations are covered in full. If the Immunization is done during an office visit, the office visit copayment will apply.	1	01000	2	1	1			1			2	16.00	1	1		2				2					2	Routine Physicals are covered in full. If the routine physical is done during an office visit, the office visit copayment will apply.	2	00111										2									2					2	1		2				2						PAP & Pelvic exams are covered in full. If the PAP & Pelvis exam is done during an office visit, the office visit copayment will apply.	2	
H3351	004	2	01	01	10000		2	2				2	2			0011010001	1																																				2																2		2			2					2	Disease management and congestive heart program may require referral	1	01000			2						2				2	3		2				2	Office visit copayment may apply if done during office visit	1	01000	2	1	1			1			2	16.00	1	2		2				2					2	There is no copayment for Routine Physicals if done in conjunction with an office visit. A $16 office visit copayment will apply.	2	00111										2									2					2	1		2				2						There is no copayment for PAP/Pelvic exams if done in conjunction with an office visit. A $16 office visit copayment will apply.	2	
H3351	006	1	01	01	10000		1	2		2		2	2			0011010101	1																																				2																2		2			2					2	Disease managerment and congestive heart program may require referral. Health club/fitness classes benefit is up to $40 per month membership fee at the health club, fitness center or qualified weight management program of the members choosing.  (You may apply this $40/month towards tuition for Weight Watchers or any qualified hospital weight management program).	1	01000			2						2				2	1		2				2	If given during an office visit, your office visit co-payment applies.	2	01000	2	1	1			1	2	10	1	5.00	1	2		2				2					2	You pay a $5. co-payment for each office visit or consultation per provider per day and a 10% co-insurance for Medications and materials administered and procedures performed during an office visit of consultation. The 10% co-insurance payment goes toward the annual out of pocket maximum of $2,500. for all co-insurance services.	2	00110										2	2	2			10	10			1					2	2		2				2						You pay a 10% co-insurance up to the annual out of pocket maximum of $2,500 for all co-insurance services.	1	2
H3351	007	1	01	01	10000		1	1				1	1			0011010001	1																																				2																2		2			2					2	Disease management and congestive heart program may require referral	1	01000			2						2				2	1		2				2	Office visit compayment will apply if given during office visit.	1	01000	1	1	1			1			2	15.00	1	2		2				2					2		2	00111										2									2	15.00	15.00			1	2		2				2						You pay a $15 copayment per provider per day for covered services from your Primary Care Physician.	2	2
H3351	008	1	01	01	10000		1	1				1	1			0011010001	1																																				2																2		2			2					2	Referral may be needed for Congestive Heart Program and Disease Management	1	01000			2						2				2	1		2				2	If the Immunization is done in conjunction with an office visit, there is no charge for the Immunization. You pay a $7.00 copayment for each office visit and/or consultation per provider per day	2	01000	1	1	1			1	2	15	1	7.00	1	2		2				2					2	If the Immunization is done in conjunction with an office visit, there is no charge for the Immunization. You pay a $7.00 copayment for each office visit and/or consultation per provider per day and a 15% coinsurance for medications and materials administered and procedures performed during an office visit. The 15% coinsurance payment goes toward the annual out of pocket maximum of $3,000.	2	00110										2	2	2			15	15			1					2	2		2				2						If the PAP/Pelvic exam is done in conjunction with an office visit, there is no charge for the PAP/Pelvis exam. You pay a $7.00 copayment for each office visit and/or consultation per provider per day and a 15% coinsurance for medications and materials administered and procedures performed during an office visit. The 15% coinsurance payment goes toward the annual out of pocket maximum of $3,000.	1	2
H3351	009	1	01	01	10000		2	2				2	2			0011010001	1																																				2																2		2			2					2	Disease Management and Congestive Heart programs may require a referral.	1	01000			2						2				2	3		2				2	There is no copayment for the immunization. If the immunization is done in conjunction with an office visit, the office visit copayment will apply.	2	01000	2	1	1			1			2	7.00	1	2		2				2					2		2	00111										2	2	2			15	15			1					2	1		2				2							2	2
H3351	801	1	01	01	10000		2	2				2	2			0011010001	1																																				2																2		2			2					2	Disease management and congestive heart program may require referral.	1	01000			2						2				2	3		2				2	A separate office co-payment may apply for immunizations	1	01000	2	1	1			1			2	20.00	1	2		2				2					2		2	00101										2									2					2	1		2				2							2	
H3351	802	1	01	01	10000		1	1		1		1	1			0011010101	1																																				2																2		2			2					2	Disease managerment and congestive heart program may require referral. Health club/fitness classes benefit is up to $40 per month membership fee at the health club, fitness center, or qualified weight management program of the members choosing. (You may apply this $40/month towards tuition for Weight Watchers or any qualified hospital weight management program).	1	01000			2						2				2	3		2				2	A separate office co-payment may apply for immunization	1	01000	1	1	1			1			2	20.00	1	2		2				2					2		2	00111										2									2					2	1		2				2							2	
H3359	001	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-based symptom assessments, self care instructions and member education 24 hours a day.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is necessary for network providers.	2	01000	1	1	1			1			2	0.00	1	1		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.	2	2
H3359	019	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-based symptom assessments, self care instructions and member education 24 hours a day.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is necessary for network providers.	2	01000	1	1	1			1			2	0.00	1	1		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.	2	2
H3359	021	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-based symptom assessments, self care instructions and member education 24 hours a day.	2	01000			2	2			20		1				2	2		2				2	No referral is necessary for network providers.	2	01000	1	1	1			1	2	0	1		2	2		2				2					2		2	01000										2									2					2	2		2				2						As per Medicare, Pap smears are covered once every two years or annually for beneficiaries at high risk.Benefit is consistent with Medicare FFS.Calendar year deductible does not apply to Pap smears.	2	
H3359	801	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs)  who provide algorithm-base symptom assessments, self care instructions and member education 24 hours a day.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is necessary for network providers.	2	01000	1	1	1			1			2	10.00	1	1		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.	2	2
H3359	802	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-base symptom assessments, self care instructions and member education 24 hours a day.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is neccessary for network providers.	2	01000	1	1	1			1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.	2	2
H3361	019	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	020	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	021	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	022	1	01	01	00101		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	023	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	024	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	025	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	026	1	01	01	00101		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	027	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	028	1	01	01	00101		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	029	1	01	01	00101		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2		1	00101	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	030	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2	10.00			1	2		2				2		1	00101	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2	10.00	10.00			1	2		2				2							2	2
H3361	031	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2	$0 copay for Medicare covered immunizations.	1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	032	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2	$0 copay for Medicare covered immunizations.	1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	034	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2	$0 copay for Medicare covered immunizations.	1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3361	035	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00101			2						2				2	2		2				2	$0 copay for Medicare covered immunizations.	1	00101	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H3362	003	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	004	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	10.00	20.00	1	2		2				2	If the immunization is administere4d by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $10 primary/ $20 specialist.	2	01000	1	1	1			1			2	10.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $10 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	013	2	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	10.00	20.00	1	2		2				2	If the immunization is administere4d by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $10 primary/ $20 specialist.	2	01000	1	1	1			1			2	10.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $10 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	801	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	802	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	803	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	804	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	805	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3362	806	1	01	01	10000			1	1	1	1	1		1	1	1110100111	1																																				2																2		2			2					2	Advanced Care Planning is an early intervention benefit providing long term planning and psychosocial support to members diagnosed with a serious or life limiting illness, via home visits.  This does not count against the home care limit or require a copayment.  Requires a pre-authorization for out of area or out of plan provider.  There is a limit of six visits per calendar year.The SilverSneakers Fitness Program is a unique physical activity, lifestyle and social oriented program, designed to encourage members to increase their levels  of physical activity and motivate them to continue to be active.	2	01000	1	1	1						2	0.00	5.00	20.00	1	2		2				2	If the immunization is administered by the primary physician, neither authorization nor a referral is required.  If it is administered by a specialist, then a referral is required but not authorization.Flu, pneumonia, Hep B are covered in full.  All other services subject to $5 primary/ $20 specialist.	2	01000	1	1	1			1			2	5.00	1	3		2				2					2	Exam must  be performed by the member's Primary Care Physician.Depending on the site of service, a separate office visit copay may apply.	2	01000		1	01		1					1									2					2	3		2				2					2	Once every 24 months, every 12 months if high risk.Pap smears are covered in full.  Depending on the site of service, a separate $5 Primary Care Physician or $20 Specialty office visit copayment will apply.No referral necessary for Medicare covered screenings.	2	
H3366	001	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	005	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	007	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	008	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	009	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	010	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	011	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	012	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	013	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	014	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	015	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3366	016	1	01	01	00101		1	1		1	1					0000010111	1																																				2																2		2			2					2	WellQuest Fitness Program - includes specialized group exercise classes and membership at selected fitness centers.	1	00100	1	1	1						2				2	3		2				2	No office copay applies if visit is solely for immunizations.Other immunizations covered: Hepatities B vaccine if at intermediate or high-risk.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Office visit copay may apply.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3370	001	1	01	01	01000		1	1	1	1	1	1			1	0110110111	1																																				2																2		2			2					2	Health Education/WellnessSome programs are targeted to at-risk individuals only.Health Club MembershipThe SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels.  Membership allows access to contracted full-service fitness facilities throughout your area.  While each fitness facility may vary slightly in amenities, care has been taken to ensure all facilities provide a variety of exercise options. The SilverSneakers Fitness Program Offers: Easy enrollment at local, conveniently located fitness facilities. No initiation fee, no contract, and no hassles. SilverSneakers Fitness Classes - a workout with seated support designed to improve body strength and flexibility. Initial health assessments with friendly fitness facility staff. Senior Advisors, contact for information and personalized, friendly service.	2	01000			2						2	0.00			1	3		2				2	CopaymentOffice visit copayment applies if other services are rendered during visit.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	Routine PhysicalYou pay $10 for each exam rendered by your network PCP, and $25 for each exam rendered by a network specialist.	2	01000										2									2	0.00	0.00			1	3		2				2						Coverage/CopaymentPlan covers additional pap smears as ordered by PCP or network specialist.  The office visit copayment may apply.	2	2
H3370	002	1	01	01	01000		1	1	1	1	1	1			1	0110110111	1																																				2																2		2			2					2	Health Education/WellnessSome programs are targeted to at-risk individuals only.Health Club MembershipThe SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels.  Membership allows access to contracted full-service fitness facilities throughout your area.  While each fitness facility may vary slightly in amenities, care has been taken to ensure all facilities provide a variety of exercise options. The SilverSneakers Fitness Program Offers: Easy enrollment at local, conveniently located fitness facilities. No initiation fee, no contract, and no hassles. SilverSneakers Fitness Classes - a workout with seated support designed to improve body strength and flexibility. Initial health assessments with friendly fitness facility staff. Senior Advisors, contact for information and personalized, friendly service.	2	01000			2						2	0.00			1	3		2				2	CopaymentOffice visit copayment applies if other services are rendered during visit.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	Routine PhysicalYou pay $10 for each exam rendered by your network PCP, and $25 for each exam rendered by a network specialist.	2	01000										2									2	0.00	0.00			1	3		2				2						Coverage/CopaymentPlan covers additional pap smears as ordered by PCP or network specialist.  The office visit copayment may apply.	2	2
H3370	003	1	01	01	01000		1	1	1	1	1	1			1	0110110111	1																																				2																2		2			2					2	Health Education/WellnessSome programs are targeted to at-risk individuals only.Health Club MembershipThe SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels.  Membership allows access to contracted full-service fitness facilities throughout your area.  While each fitness facility may vary slightly in amenities, care has been taken to ensure all facilities provide a variety of exercise options. The SilverSneakers Fitness Program Offers: Easy enrollment at local, conveniently located fitness facilities. No initiation fee, no contract, and no hassles. SilverSneakers Fitness Classes - a workout with seated support designed to improve body strength and flexibility. Initial health assessments with friendly fitness facility staff. Senior Advisors, contact for information and personalized, friendly service.	2	01000			2						2	0.00			1	3		2				2	CopaymentOffice visit copayment applies if other services are rendered during visit.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	Routine PhysicalYou pay $10 for each exam rendered by your network PCP, and $25 for each exam rendered by a network specialist.	2	01000										2									2	0.00	0.00			1	3		2				2						Coverage/CopaymentPlan covers additional pap smears as ordered by PCP or network specialist.  The office visit copayment may apply.	2	2
H3370	004	1	01	01	01000		2	2	2	2	2	2			2	0110110111	1																																				2																2		2			2					2	Health Education/WellnessSome programs are targeted to at-risk individuals only.Health Club MembershipThe SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels.  Membership allows access to contracted full-service fitness facilities throughout your area.  While each fitness facility may vary slightly in amenities, care has been taken to ensure all facilities provide a variety of exercise options. The SilverSneakers Fitness Program Offers: Easy enrollment at local, conveniently located fitness facilities. No initiation fee, no contract, and no hassles. SilverSneakers Fitness Classes - a workout with seated support designed to improve body strength and flexibility. Initial health assessments with friendly fitness facility staff. Senior Advisors, contact for information and personalized, friendly service.	2	01000			2						2	0.00			1	3		2				2	CopaymentOffice visit copayment applies if other services are rendered during visit.	2	01000	2	1	1			1			2	10.00	1	2		2				2					2	Routine PhysicalYou pay $10 for each exam rendered by your network PCP, and $25 for each exam rendered by a network specialist.	2	01000										2									2	0.00	0.00			1	3		2				2						Coverage/CopaymentPlan covers additional pap smears as ordered by PCP or network specialist.  The office visit copayment may apply.	2	2
H3370	005	1	01	01	01000		1	1	1	1	1	1			1	0110110111	1																																				2																2		2			2					2	Health Education/WellnessSome programs are targeted to at-risk individuals only.Health Club MembershipThe SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels.  Membership allows access to contracted full-service fitness facilities throughout your area.  While each fitness facility may vary slightly in amenities, care has been taken to ensure all facilities provide a variety of exercise options. The SilverSneakers Fitness Program Offers: Easy enrollment at local, conveniently located fitness facilities. No initiation fee, no contract, and no hassles. SilverSneakers Fitness Classes - a workout with seated support designed to improve body strength and flexibility. Initial health assessments with friendly fitness facility staff. Senior Advisors, contact for information and personalized, friendly service.	2	01000			2						2	0.00			1	3		2				2	CopaymentOffice visit copayment applies if other services are rendered during visit.	2	01000	1	1	1			1			2	0.00	1	2		2				2					2	Routine PhysicalYou pay $0 for each exam rendered by your network PCP, and $10 for each exam rendered by a network specialist.	2	01000										2									2	0.00	0.00			1	3		2				2						Coverage/CopaymentPlan covers additional pap smears as ordered by PCP or network specialist.  The office visit copayment may apply.	2	2
H3379	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	002	1	01	01													2																																																															Evercare offers the following benefits within the nursing home:- Physician visits in a nursing home.- Nurse Practitioner visits in a nursing home.- Family counsels in a nursing home.For purposes of the ACR, these services were included under category 7 (Health Care Professional Services.)		01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, enrollees may be charged a copayment/coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	There is no separate copayment for the routine physical exam. Enrollees may be assessed a copayment as described in section 7 of the PBP if the exam andadditional services are obtained in a physician's office; or outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam andadditional services at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	If additional services are received during the visit for preventive services, enrollees may be charged a copayment/coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	005	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	007	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	009	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	010	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	011	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	012	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	013	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	014	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	015	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	016	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3379	017	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3384	013	1	01	01													2																																																																	01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams. You are covered up to one (1) exam every year. If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	20.00		20.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two (2) years. If you are at high risk of cervical cancer or have had an abnornal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.If services rendered include a phyisican office visit, a copayment may apply.	2	2
H3384	015	1	01	01													2																																																																	01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams. You are covered up to one (1) exam every year. If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	20.00		20.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two (2) years. If you are at high risk of cervical cancer or have had an abnornal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.If services rendered include a phyisican office visit, a copayment may apply.	2	2
H3384	019	1	01	01													2																																																																	01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams. You are covered up to one (1) exam every year. If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	20.00		20.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two (2) years. If you are at high risk of cervical cancer or have had an abnornal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.If services rendered include a phyisican office visit, a copayment may apply.	2	2
H3384	022	1	01	01													2																																																																	01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams. You are covered up to one (1) exam every year. If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	20.00		20.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two (2) years. If you are at high risk of cervical cancer or have had an abnornal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.If services rendered include a phyisican office visit, a copayment may apply.	2	2
H3387	005	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	1		2			2					2	AmeriChoice also provides tele-medicine benefit to members.Please call Plan for details.	2	01000			2						2	0.00			1	3		2				2	Office visit copay may apply.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office visit copay may apply.	2	2
H3387	006	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	1		2			2					2	AmeriChoice also provides tele-medicine benefit to members.Please call Plan for details.	2	01000			2						2	0.00			1	3		2				2	Office visit copay may apply.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office visit copay may apply.	2	2
H3388	001	1	01	01	01000			1	1	1		1		1		1110000101	1																																				2				0.00	0.00	0.00	0.00	0.00	0.00		0.00		12.00	12.00		1		2			2					2	The $12.00 office copay is collected for Preventative Counsleling visits as well as Nutrition Therapy.  The plan covers a variety of services.  Ask CDPHP for details.	2	01000			2						2				2	3		2				2	Doctor office visit copayment may apply, if service received is not incident of other physican services received during the same visit.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Doctor office visit copayment may apply, if service received is not incident of other physican services received during the same visit.	2	
H3449	004	2	01	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	If provider of service bills for an office visit, an office visit copay will apply.	2	01000	1	1	2	1	6	1			2	15.00	1	1		2				2					2	If provider of service bills for an office visit, an office visit copay will apply.Additional screening exams up to 1 exam every 12 months.	2	01000	1	1	11	2	2	1	1	6	6	1									2					2	3		2				2					2	If provider of service bills for an office visit, an office visit copay will apply.Additional screening exams up to 1 exam every 12 months.	2	
H3449	005	1	01	01	01000		1	1				1	1			0011010001	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	If the provider bills for an Office Visit in conjunction with the diagnostic services, a copay will apply.	1	01000	1	1	2	1	6	1			2	15.00	1	1		2				2					2	Additional screening exams up to 1 exam every 12 months.	2	01000	1	1	11	2	2	1	1	6	6	1									2					2	3		2				2					2	If the provider bills for an Office Visit in conjunction with the diagnostic services, a copay will apply.Additional screening exams up to 1 exam every 12 months.	2	
H3456	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	004	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	006	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	007	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	008	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	009	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	010	1	01	01	01000									1		1000000000	1																																				2																2		2			2					2	Evercare offers the following benefits within the nursing home:Physician visitsNurse Practioner visits andFamily Counsels	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	011	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	012	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3456	013	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3653	004	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3653	005	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3653	006	2	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3653	007	2	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3653	008	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3653	009	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	PCP or specialist office visit copay may apply.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	PCP office visit copay applies.  There is no additional charge for a routine physical.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PCP or specialist office copay may apply.	2	
H3655	001	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	011	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	012	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	013	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	016	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	017	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	027	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	028	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3655	029	1	01	01													2																																																																	00111			2						2				2	1		2				2		1	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3657	009	1	01	01													2																																																																	01000			2						2				2	3		2				2	Doctor office visit may apply.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	15.00			1	3		2				2						Doctor office visit may apply.	2	2
H3657	010	1	01	01													2																																																																	01000			2						2				2	3		2				2	Doctor office visit may apply.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	20.00			1	3		2				2						No refferral required for in-network OB/GYN providers.  A limit of 1 routine pap smear/pelvic exam every year.  Doctor office visit copayment may apply.	2	2
H3659	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	002	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	003	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	004	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	007	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	017	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	018	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	029	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	031	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	032	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	033	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	034	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	035	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	036	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	037	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	038	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	039	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	040	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	041	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	042	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	043	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	044	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3659	801	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H3660	003	1	01	01	01000			2	2		2	2				0110000011	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3660	010	1	01	01	01000			2	2		2	2				0110000011	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	2	1	2	1	3	1			2		2	1		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3664	001	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H3664	003	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H3664	004	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H3664	008	2	01	01	01000						1					0000000010	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H3664	009	1	01	01	01000						1					0000000010	1																																				2																2		2			2					2		2	00100			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H3668	005	1	01	01													2																																																																	01000			2						2	15.00			1	2		2				2		2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	25.00			1	2		2				2							2	2
H3672	001	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2			0.00	0.00	0.00	0.00	50.00				0.00	0.00				1		2			2					2		2	00100			2						2	10.00			1	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the pap smear.  Office visit copay applies when being treated by a physician for services that require a copay in addition to the pelvic exam.  Members will not be charged two copays when receiving a pelvic exam in additional to other services	2	2
H3672	003	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2			0.00	0.00	0.00	0.00	50.00				0.00	0.00				1		2			2					2		2	00100			2						2	10.00			1	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the pap smear.  Office visit copay applies when being treated by a physician for services that require a copay in addition to the pelvic exam.  Members will not be charged two copays when receiving a pelvic exam in additional to other services	2	2
H3672	009	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2			0.00	0.00	0.00	0.00	50.00				0.00	0.00				1		2			2					2		2	00100			2						2	10.00			1	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the pap smear.  Office visit copay applies when being treated by a physician for services that require a copay in addition to the pelvic exam.  Members will not be charged two copays when receiving a pelvic exam in additional to other services	2	2
H3672	010	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2			0.00	0.00	0.00	0.00	50.00				0.00	0.00				1		2			2					2		2	00100			2						2	10.00			1	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the pap smear.  Office visit copay applies when being treated by a physician for services that require a copay in addition to the pelvic exam.  Members will not be charged two copays when receiving a pelvic exam in additional to other services	2	2
H3673	801	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office vist may apply.	2	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2	A $20 copayment will apply if performed by a specialist.	2	00111		1	01		2		1		3	1									2					2	3		2				2					2	An office visit copayment may apply.	2	
H3706	001	1	01	01	00101		1	1	1				1		1	0101110001	1																																				2																2		2			2					2		2	00101			2						2				2	2		2				2		1	00101	1	1	2	1	3	1			2		2	2		2				2					2		1	00101	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	If services rendered are in conjunction with an office visit, the appropriate office visit copay will apply	2	
H3749	001	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	01000			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3749	004	1	01	01													2																																																																	01000			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3749	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3755	001	1	01	01	00111			1			1	1	1		1	0011100011	1																																				2																2		2			2					2	No authorization required for Newsletter.	1	00111	1	1	1						2	15.00	15.00	15.00	1	3		2				2	Routine immunizations except for Influenza and Pneumococcal vaccines, will have a $15 co-pay, all immunizations except for influenza require a physcian's referral.If the Member does not see the physician and receives immunizations other than Influenza or Pneumococcal, the immunization co-pay will apply.  If the Member sees the physician and receives immunization, only the office visit co-payment applies.	1	00100	1	1	2	1	3	1			2		2	1		2				2					2	Enrollee must receive routine physical exam from his or her Primary Care Physician.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Enrollee must receive Pap Smears and Pelvic Exams from her Primary Care Physician or a contracting OB/GYN in her Primary Care Physician's network.  Additional benefit offered entitles member to one routine pap/pelvic per year instead of one every two years.	1	
H3805	001	1	01	01													2																																																																	00110			2						2	0.00			1	2		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3805	005	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3805	007	1	01	01													2																																																																	00110			2						2	0.00			1	2		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3805	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H3856	007	2	01	01	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed, a copayment will apply.	2	
H3856	010	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed, a copayment will apply.	2	
H3864	001	1	01	01													2																																																																	01000			2						2				2	2		2				2	Section B - Screen 14b - Enrollee must receive Authorization from one or more of the following, except for Influenza Immunization:No referral required for Influenza, Pneumonia and DT (accident related only)	2	01000	2	1	2	1	2	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	2		2				2						Section B - Screen 14d - Enrollee must receive Authorization for Additional Smears/Exams from one or more of the following:Routine Pap Smears do not require a referral.  Follow-up Smears/Exams do require a referral.	2	
H3864	002	1	01	01													2																																																																	01000			2						2				2	2		2				2	Section B - Screen 14b - Enrollee must receive Authorization from one or more of the following, except for Influenza Immunization:No referral required for Influenza, Pneumonia and DT (accident related onlt)	2	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	2		2				2						Section B - Screen 14d - Enrollee must receive Authorization for Additional Smears/Exams from one or more of the following:Routine Pap Smears do not require a referral.  Follow-up Smears/Exams do require a referral.	2	
H3864	005	1	02	01													2																																																																	01000			2						2				2	2		2				2	Section B - Screen 14b - Enrollee must receive Authorization fron one or more of the following, except for Influenza Immunization:No referral reqiured for Influenza, Pneumonia and DT (accident related only)	2	01000	2	1	2	1	2	1			2	10.00	1	2		2				2					2	All Office Visits performed by the member's PCP will require a $10 copay.  All Office Visits performed by a provider other than the member's PCP will require a $20 Copay.	2	01000										2									2					2	2		2				2						Section B - Screen 14d - Enrollee must receive Authorization for Additional Smears/Exams from one or more of the following:Routine Pap Smears do not require a referral.  Follow-up Smears/Exams do require a referral.	2	
H3907	001	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	002	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	003	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	005	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	006	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	007	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	009	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	010	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	015	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	016	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	017	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	018	1	01	01	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3907	801	1	01	01	01000				1							0100000000	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	No copayment applies.	2							2																				01000										2									2					2	2		2				2							2	
H3912	001	1	04	01													2																																																															Evercare offers the following benefits within the nursing home: Physician visits & Nurse Practitioner visits in a nursing home. Family Counsels in a nursing home.		10000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Primary Care Team: Nurse practitioner and Primary Care Physician.No copayment for Influenza and Pneumococcal vaccinations.  For Hepatitis B vaccinations, members may be charged a copayment / coinsurance depending on the services received and on the place of service. Office visit copayment is $0 if services are provided in the Nursing Facility. $15 for services at the PCT, $25 for services at a preferred specialist for medicare covered benefits.	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Copayment is $0 if services are provided in the Nursing Facility. For services not in a nursing facility member pays 100% (Same as Medicare).Primary Care Team: Nurse Practitioner and Primary Care Physician	1	00100										2									2					2	1		2				2						Primary Care Team: Nurse Practitioner and Primary Care PhysicianEnrollees maybe charged copayment / coinsurance depending on services received and place of service. Members may be charged a copayment / coinsurance depending on the services received and on the place of service. Office visit copayment is $0 if services are provided in the Nursing Facility. $15 for services at the PCT, $25 for services at a preferred specialist for medicare covered benefits.	1	
H3912	002	1	04	01													2																																																															Evercare offers the following benefits within the nursing home: Physician visits & Nurse Practitioner visits in a nursing home. Family Counsels in a nursing home.		10000	1	1	1						2	0.00	0.00	0.00	1	3		2				2	Primary Care Team: Nurse practitioner and Primary Care Physician.No copayment for Influenza and Pneumococcal vaccinations.  For Hepatitis B vaccinations, members may be charged a copayment / coinsurance depending on the services received and on the place of service. Office visit copayment is $0 if services are provided in the Nursing Facility. $15 for services at the PCT, $25 for services at a preferred specialist for medicare covered benefits.	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Copayment is $0 if services are provided in the Nursing Facility. For services not in a nursing facility member pays 100% (Same as Medicare).Primary Care Team: Nurse Practitioner and Primary Care Physician	1	00100										2									2					2	1		2				2						Primary Care Team: Nurse Practitioner and Primary Care PhysicianEnrollees maybe charged copayment / coinsurance depending on services received and place of service. Members may be charged a copayment / coinsurance depending on the services received and on the place of service. Office visit copayment is $0 if services are provided in the Nursing Facility. $15 for services at the PCT, $25 for services at a preferred specialist for medicare covered benefits.	1	
H3916	001	1	04	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Members may self-refer to Highmark's health education programs as well as Blues on Call (nurse hotline).Condition management programs available for COPD, ESRD, Diabetic, CHF, and CAD members.Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the plan pays 100% for the program.  There is a 20% coinsurance for diagnostic/lab services not received at a network participating facility. FreedomBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	3		2				2	A $15 office visit copayment may appy if E&M service is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	An office visit copayment may apply if an E&M service is performed in addition to the PAP smear.	2	2
H3916	002	1	04	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Members may self-refer to Highmark's health education programs as well as Blues on Call (nurse hotline).Condition management programs available for COPD, ESRD, Diabetic, CHF, and CAD members.Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the plan pays 100% for the program.  There is a 20% coinsurance for diagnostic/lab services not received at a network participating facility. FreedomBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	3		2				2	A $15 office visit copayment may appy if E&M service is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	An office visit copayment may apply if an E&M service is performed in addition to the PAP smear.	2	2
H3916	003	1	04	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Members may self-refer to Highmark's health education programs as well as Blues on Call (nurse hotline).Condition management programs available for COPD, ESRD, Diabetic, CHF, and CAD members.Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the plan pays 100% for the program.  There is a 20% coinsurance for diagnostic/lab services not received at a network participating facility. FreedomBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	3		2				2	A $15 office visit copayment may appy if E&M service is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	An office visit copayment may apply if an E&M service is performed in addition to the PAP smear.	2	2
H3916	004	1	04	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Members may self-refer to Highmark's health education programs as well as Blues on Call (nurse hotline).Condition management programs available for COPD, ESRD, Diabetic, CHF, and CAD members.Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the plan pays 100% for the program.  There is a 20% coinsurance for diagnostic/lab services not received at a network participating facility. FreedomBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	3		2				2	A $15 office visit copayment may appy if E&M service is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	An office visit copayment may apply if an E&M service is performed in addition to the PAP smear.	2	2
H3931	004	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3931	019	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3931	054	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3931	055	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3931	056	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3931	057	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H3931	801	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3931	803	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Health Education/Wellness Programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B, Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).MMA Effective 03/01/04:Changed Hepatitis B to $0 copay.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Effective 03/01/04:Changed Routine Physical to $0 Copay.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Effective 03/01/04:Changed Pelvic Exam to $0 Copay.	2	
H3949	002	1	01	01													2																																																																	00001			2						2				2	2		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2									2					2	2		2				2						Members can self-refer to participating specialists without a referral.	2	
H3949	007	1	01	01													2																																																																	00001			2						2				2	2		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2									2					2	2		2				2						Members can self-refer to participating specialists without a referral.	2	
H3949	008	1	01	01													2																																																																	00001			2						2				2	2		2				2		1	00001	1	1	1			1			2		2	2		2				2					2	Elder Health Practitioners perform routine physical exams at no cost to the enrolee.	2	00001										2									2					2	2		2				2						Members can self-refer to participating specialists without a referral.	2	
H3952	008	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3952	009	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3952	018	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Cardiac Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply. Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.	2	2
H3952	020	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	30.00	0.00	30.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3952	024	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	30.00	0.00	30.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3952	025	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Cardiac Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply. Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.	2	2
H3952	026	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.	2	2
H3952	027	1	02	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.	2	2
H3952	801	1	01	01	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	35.00	0.00	35.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3952	802	1	01	01	10000			1	1	1		1	1	1	1	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	35.00	0.00	35.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3954	003	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	004	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	005	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	006	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	007	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	008	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	2	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	009	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	010	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	011	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	012	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	013	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	014	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3954	015	1	01	01	01000		2	2		2	2				2	0000110111	1																																				2																2		2			2					2		2	00111			2						2				2	3		2				2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with immunization	1	01000	2	1	2	1	3	1			2	10.00	1	3		2				2					2	OV copay may be charged if consultation/E&M Services are supplied in conjunction with Routine Physical	2	00111										2									2					2	3		2				2						OV copay may be charged if consultation/E&M Services are supplied in conjunction with Pap smear	1	
H3957	003	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	006	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	008	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	016	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	020	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	021	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	022	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3957	023	1	01	01	01000		2	2	2	2	2	2	2			0111010111	1																																				2																2		2			2					2	Plan pays 20% of Medicare allowed amount for Dean Ornish program for those enrolled in a Medicare-sponsored program.  For beneficiaries not enrolled in a Medicare-covered Dean Ornish program, the Plan pays 100% for the program.SecurityBlue offers the SilverSneakers Fitness Program Membership.  The SilverSneakers Fitness Program is a total health and fitness program that is beneficial for Medicare-eligible persons of all fitness levels. Membership allows access to participating full-service fitness centers throughout the service area.	2	00001			2						2				2	2		2				2	Office visit copayments may apply if an E&M serivce is performed in addition to the immunization.Immunizations for the purpose of travel are not covered.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment applies if routine physical is not performed by PCP.	2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit copayments may apply if an E&M serivce is performed in addition to the pap smear.  No referral for annual routine gynecological exams, inlcuding Pap test and pelvic exams, when obtained from network providers.  If the annual, routine exam is provided by a PCP, the copayment is $10.If a problem which requires further treatment is discovered at the routine exam or during a PCP-referred visit to the gynecologist, the member may be treated by the gynecologist for a 90-day period without a referral from the PCP.  The gynecologist also may refer the member for any necessary diagnostic testing during this 90-day period.	2	2
H3959	001	1	01	01	00111		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B - #14A HealthEd/Wellness - Base 1 - Question: Do you offer any Additional Benefits?  Selected enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations Base 1 - Question:  Indicate whether a separate office visit cost share applies for services:  Office visit copayment may apply.Section B - #14b Immunizations Base 3 - Question:  Enrollee must receive authorization from one or more of the following, except Influenza Immunization:  No authorization necessary for network providers.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question: Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.Section B #14C Routine Physicals Base 3  Question:  Indicate Copayment amount per exam.   $10 PCP copayment or $25 specialist copayment may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4 Question: Enrollee must receive Authorization for Additional Smears/Exams for one or more of the following:    No authorization for network providers.	2	
H3959	002	1	01	01	00111		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B - #14A HealthEd/Wellness - Base 1 - Question: Do you offer any Additional Benefits?  Selected enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations Base 1 - Question:  Indicate whether a separate office visit cost share applies for services:  Office visit copayment may apply.Section B - #14b Immunizations Base 3 - Question:  Enrollee must receive authorization from one or more of the following, except Influenza Immunization:  No authorization necessary for network providers.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question Enrolllee must receive authorization from one or more of the following:   No authorization necessary for network providers .Section B #14C Routine Physicals Base 3  Question:  Indicate Copayment amount per exam.   $10 PCP copayment or $25 specialist copayment may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4 Question: Enrollee must receive Authorization for Additional Smears/Exams for one or more of the following:    No authorization for network providers.	2	
H3959	004	1	01	01	00111		2	2	2			2	2	2	2	1111110001	1																																				2																2		2			2					2	Section B  #14A Health Ed/Wellness 1  Base 1  Question:  Do you offer any additional, mandatory or optional suplemental benefits?   Selected enhanced benefits include weight and stress management.	2	01000	1	2	1						2				2	3		2				2	Section B  #14B Immunizations - Base 1 Question: Indicate whether a separate office visit cost share applies for services:   Office visit copayment may apply.Section B  #14B Immunizations Base 3  Question:  Enrollee must receive Authorization from one or more of the following, except for Influenza Immunizations:   No authorizaiton necessary for network providers.	2	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question:  Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.Section B #14c Routine Physicals Base 3 Question:  Indicate Copayment amount per exam.   $25 PCP copayment or $35 specialist copayment may apply, depending on which provider performs this service.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4  Question:  Enrollee must receive authorization for Additional Smears/Exams for one or more of the following:   No authorization for network providers.	2	
H3959	006	1	01	01	00111		2	2	2			2	2	2	2	1111110001	1																																				2																2		2			2					2	Section B  #14A Health Ed/Wellness 1  Base 1  Question:  Do you offer any additional, mandatory or optional suplemental benefits?   Selected enhanced benefits include weight and stress management.	2	01000	1	2	1						2				2	3		2				2	Section B  #14B Immunizations - Base 1 Question: Indicate whether a separate office visit cost share applies for services:   Office visit copayment may apply.Section B  #14B Immunizations Base 3  Question:  Enrollee must receive Authorization from one or more of the following, except for Influenza Immunizations:   No authorization necessary for network providers.	2	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question:  Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.Section B #14c Routine Physicals  Base 3  Question:  Indicate Copayment amount per exam.   $25 PCP copayment or $35 specialist copayment may apply, depending on which provider performs this service.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4  Question:  Enrollee must receive authorization for Additional Smears/Exams for one or more of the following:   No authorization for network providers.	2	
H3959	008	1	01	01	00111		2	2	2			2	2	2	2	1111110001	1																																				2																2		2			2					2	Section B  #14A Health Ed/Wellness 1  Base 1  Question:  Do you offer any additional, mandatory or optional suplemental benefits?   Selected enhanced benefits include weight and stress management.	2	01000	1	2	1						2				2	3		2				2	Section B  #14B Immunizations - Base 1 Question: Indicate whether a separate office visit cost share applies for services:   Office visit copayment may apply.Section B  #14B Immunizations Base 3  Question:  Enrollee must receive Authorization from one or more of the following, except for Influenza Immunizations:   No authorizaiton necessary for network providers.	2	01000	2	1	2	1	3	1			2	25.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question:  Enrollee must receive authorizatin from one or more of the following:   No authorization necessary for network providers.Section B #14c Routine Physicals  Base 3  Question:  Indicate Copayment amount per exam.   $25 PCP copayment or $35 specialist copayment may apply, depending on which provider performs this service.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4  Question:  Enrollee must receive authorization for Additional Smears/Exams for one or more of the following:   No authorization for network providers.	2	
H3959	010	1	01	01	00111		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B - #14A HealthEd/Wellness - Base 1 - Question: Do you offer any Additional Benefits?  Selected enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations Base 1 - Question:  Indicate whether a separate office visit cost share applies for services:  Office visit copayment may apply.Section B - #14b Immunizations Base 3 - Question:  Enrollee must receive authorization from one or more of the following, except Influenza Immunization:  No authorization necessary for network providers.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.Section B #14c Routine Physicals Base 3  Question:  Indicate Copayment amount per exam.   $10 PCP copayment or $25 specialist copayment may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4 Question: Enrollee must receive Authorization for Additional Smears/Exams for one or more of the following:    No authorization for network providers.	2	
H3959	011	1	01	01	00111		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B - #14A HealthEd/Wellness - Base 1 - Question: Do you offer any Additional Benefits?  Selected enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B - #14b Immunizations Base 1 - Question:  Indicate whether a separate office visit cost share applies for services:  Office visit copayment may apply.Section B - #14b Immunizations Base 3 - Question:  Enrollee must receive authorization from one or more of the following, except Influenza Immunization:  No authorization necessary for network providers.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.Section B #14c Routine Physicals Base 3  Question:  Indicate Copayment amount per exam.   $10 PCP copayment or $20 specialist copayment may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4 Question: Enrollee must receive Authorization for Additional Smears/Exams for one or more of the following:    No authorization for network providers.	2	
H3959	801	1	01	01	00111		2	2	2			2	2	2	2	1111110001	1																																				2																2		2			2					2	Section B  #14A Health Ed/Wellness 1  Base 1  Question:  Do you offer any additional, mandatory or optional suplemental benefits?   Selected enhanced benefits include weight and stress management.	2	01000	1	2	1						2				2	3		2				2	Section B  #14B Immunizations - Base 1 Question: Indicate whether a separate office visit cost share applies for services:   Office visit copayment may apply.Section B  #14B Immunizations Base 3  Question:  Enrollee must receive Authorization from one or more of the following, except for Influenza Immunizations:   No authorizaiton necessary for network providers.	2	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2	Section B #14c Routine Physicals Base 4  Question:  Enrollee must receive authorization from one or more of the following:   No authorization necessary for network providers.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Section B  #14d Pap/Pelvic Base 4  Question:  Enrollee must receive authorization for Additional Smears/Exams for one or more of the following:   No authorization for network providers.	2	
H3962	001	1	01	01	00001		2	2	2			2			2	0110110001	1																																				2																2		2			2					2	Enhanced Benefit: The following programs are additional programs available: Reminder program for annual mammography screening, asthma management pgroam, and a program for thos with diabetes. Nutritional therapy: There is no copay for Nutritional therapy.	2	00111	1	2	1						2				2	3		2				2	Other immunizations: Coverage is provided for medically necessary FDA approved immunizations, except immunizations for travel purposes and Lymerix. Newly FDA approved immunizations will be evaluated on a case by case basis for coverage determination.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copayment: Office visit copayment may apply. Authorization: Coverage is for an annual routine pap smear and pelvic exam. No referral is necessary for network providers for annual routine exams.	1	
H3962	002	1	01	01	00001		2	2	2			2			2	0110110001	1																																				2																2		2			2					2	Enhanced Benefit: The following programs are additional programs available: Reminder program for annual mammography screening, asthma management pgroam, and a program for thos with diabetes. Nutritional therapy: There is no copay for Nutritional therapy.	2	00111	1	2	1						2				2	3		2				2	Other immunizations: Coverage is provided for medically necessary FDA approved immunizations, except immunizations for travel purposes and Lymerix. Newly FDA approved immunizations will be evaluated on a case by case basis for coverage determination.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copayment: Office visit copayment may apply. Authorization: Coverage is for an annual routine pap smear and pelvic exam. No referral is necessary for network providers for annual routine exams.	1	
H3962	003	1	01	01	00001		2	2	2			2			2	0110110001	1																																				2																2		2			2					2	Enhanced Benefit: The following programs are additional programs available: Reminder program for annual mammography screening, asthma management pgroam, and a program for thos with diabetes. Nutritional therapy: There is no copay for Nutritional therapy.	2	00111	1	2	1						2				2	3		2				2	Other immunizations: Coverage is provided for medically necessary FDA approved immunizations, except immunizations for travel purposes and Lymerix. Newly FDA approved immunizations will be evaluated on a case by case basis for coverage determination.	1	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copayment: Office visit copayment may apply. Authorization: Coverage is for an annual routine pap smear and pelvic exam. No referral is necessary for network providers for annual routine exams.	1	
H3964	001	1	01	01	01000			1	1	1		1	1	1	1	1111100101	1																																				2				0.00	0.00	0.00	0.00	2.00	2.00		0.00	0.00	0.00	0.00	0.00	1		2			2					2	The Plan covers water exercise classes and fitness club membership only. All other fitness classes are not covered. Member may be required to contact Member Services for coordination of these two benefits.  Copayment (cost sharing) is  reimbursible when program requirements are met.  Plan covers 2 pharmacist consultations per year to review potential member drug interactions and other phamaceutical related issues, with no copay.	2	01000			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	2	2	3	3	1									2					2	2		2				2					2		2	
H3964	002	1	01	01	01000			1	1	1		1	1	1	1	1111100101	1																																				2				0.00	0.00	0.00	0.00	2.00	2.00		0.00	0.00	0.00	0.00	0.00	1		2			2					2	The Plan covers water exercise classes and fitness club membership only. All other fitness classes are not covered. Member may be required to contact Member Services for coordination of these two benefits.  Copayment (cost sharing) is  reimbursible when program requirements are met.  Plan covers 4 pharmacist consultations per year to review potential member drug interactions and other phamaceutical related issues, with no copay.	2	01000			2	2			20		1				2	1		2				2		2							2																				01000										2	2	2			20	20			1					2	1		2				2							2	2
H3972	001	1	01	01	01000		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	1		2			2					2	AmeriChoice also provides tele-medicine benefit to members.Please call Plan for details.	2	01000			2						2	0.00			1	3		2				2	Office visit copay may apply.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	3		2				2						Office visit copay may apply.	2	2
H4003	001	1	01	01	00001		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2					2		1	00100			2						2				2	2		2				2		2	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H4003	801	1	01	01													2																																																																	00100			2						2				2	2		2				2		2							2																				01000										2									2					2	2		2				2							2	
H4004	001	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	01000	1	2	1						2				2	1		2				2	Pneumonia vaccineFlu shotsHepatitis BAnti-Rabies vaccine	1	01000	2	1	2	1	3	1	4	20	1		2	2		2				2					2		2	01000										2	1	1			20	20			1					2	2		2				2							1	2
H4004	002	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	01000	1	2	1						2				2	2		2				2	Pneumonia vaccineFlu shotsHepatitis BAnti Rabies vaccine	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H4004	003	1	01	01	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2		1	01000	1	2	1						2				2	1		2				2	Pneumonia vaccineFlu ShotsHepatitis BAnti-Rabies vaccine	2	01000	2	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							1	
H4102	001	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H4102	008	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H4102	013	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H4102	014	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H4102	017	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H4152	004	1	01	01	01000				1	1						0100000100	1																																				2						0.00	0.00	10.00	10.00							1		2			2					2	There is a $10 monthly fee for the health club membership.	2	01000			2						2				2	3		2				2	Office visit copay applies if the immunization is received as part of an office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	1		2				2					2	The routine physician should be performed by the primary care provider.  A referral from the PCP is required if the physical is performed by a specialist, and the specialist copayment would apply.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	The appropriate doctor office visit copayment applies if services are received as part of an office visit. The PCP copayment applies if the pap smear is perfomed by the PCP. The specialist copayment applies if it is performed by a plan gynecologist.  A member can self refer to a plan gynecologist for the pap smear.	2	
H4152	005	1	01	01	01000				1	1						0100000100	1																																				2						0.00	0.00	10.00	10.00							1		2			2					2	There is a $10 monthly fee for the health club membership.	2	01000			2						2				2	3		2				2	Office visit copay applies if the immunization is received as part of an office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	1		2				2					2	The routine physician should be performed by the primary care provider.  A referral from the PCP is required if the physical is performed by a specialist, and the specialist copayment would apply.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	The appropriate doctor office visit copayment applies if services are received as part of an office visit. The PCP copayment applies if the pap smear is perfomed by the PCP. The specialist copayment applies if it is performed by a plan gynecologist.  A member can self refer to a plan gynecologist for the pap smear.	2	
H4152	007	1	01	01	01000				1	1						0100000100	1																																				2						0.00	0.00	10.00	10.00							1		2			2					2	There is a $10 monthly fee for the health club membership.	2	01000			2						2				2	3		2				2	Office visit copay applies if the immunization is received as part of an office visit.	2	01000	1	1	2	1	3	1			2	10.00	1	1		2				2					2	The routine physician should be performed by the primary care provider.  A referral from the PCP is required if the physical is performed by a specialist, and the specialist copayment would apply.	1	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	The appropriate doctor office visit copayment applies if services are received as part of an office visit. The PCP copayment applies if the pap smear is perfomed by the PCP. The specialist copayment applies if it is performed by a plan gynecologist.  A member can self refer to a plan gynecologist for the pap smear.	2	
H4454	002	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment can apply if there are other services received, but there will not be a charge for the immunization.1x per year	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						OB-GYN or PCP can provide the annual well visit exams.1 annual exam per year	2	
H4454	007	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment may apply when administered in physicians office. 1 per year	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per year	2	
H4456	005	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	PBP 2003 noted that Member pays $0 for exam, but $10 for doctor office visit.  Please note the following clarification made to the PBP 2004.Because a member cannot have a routine physical without seeing his/her physician and only one exam code is billed, it is more clear to state that there is a  copayment but no separate office visit copayment for routine physicals.  Also note the benefit change of increasing copayment from $10 to $15 in CY 2004.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H4456	006	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	PBP 2003 noted that Member pays $0 for exam, but $10 for doctor office visit.  Please note the following clarification made to the PBP 2004.Because a member cannot have a routine physical without seeing his/her physician and only one exam code is billed, it is more clear to state that there is a  copayment but no separate office visit copayment for routine physicals.  Also note the benefit change of increasing copayment from $10 to $15 in CY 2004.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H4456	801	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	PBP 2003 noted that Member pays $0 for exam, but $10 for doctor office visit.  Please note the following clarification made to the PBP 2004.Because a member cannot have a routine physical without seeing his/her physician and only one exam code is billed, it is more clear to state that there is a  copayment but no separate office visit copayment for routine physicals.  Also note the benefit change of increasing copayment from $10 to $15 in CY 2004.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H4456	805	1	01	01	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H4461	001	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4461	004	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4461	007	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4461	801	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4461	802	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4461	803	1	01	01	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4506	002	1	05	01	01000			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs.	2	01000			2						2				2	1		2				2	No separate copayment is required for covered Immunizations.NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Personal Physician and $15.00 for a Specialty Care Physician.Out-of-Network Benefit:  Coinsurance of 20% of eligible expenses for services received from a non-network provider.	2	01000	2	1	2	1	3	1			2		2	1		2				2					2	No copayment is required for covered Routine Physicals when provided in conjunction with an office visit; only an OV copay. NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Personal Physician and $15.00 for a Specialty Care Physician.Out-of-Network Benefit: coinsurance of 20% of eligible expenses for services received from a non-network provider.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit; only an OV copay.NOTE ON COPAYMENT: The member copayment is $5.00 for a Personal Physician and $15.00 for a Specialty Care Physician.Out-of-Network Benefit: coinsurance of 20% of eligible expenses for services received from a non-network provider.	2	
H4506	003	1	05	01	00001			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs. Prior authorization and referral is required for Disease Management.	1	00001			2						2				2	1		2				2	Member must use network providers.No separate copayment is required for covered Immunizations.  NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	1	2	1	3	1			2		2	1		2				2					2	Member must use network providers.No copayment is required for covered Routine Physicals when provided in conjunction with an office visit. NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Member must use network providers and can self-refer to a network PCP and OB/GYN.No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit.NOTE ON COPAYMENT: The member copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	
H4506	004	1	05	01	00001			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs. Prior authorization and referral is required for Disease Management.	1	00001			2						2				2	1		2				2	Member must use network providers.No separate copayment is required for covered Immunizations.  NOTE ON COPAYMENT: The member office visit copayment is $0.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	1	2	1	3	1			2		2	1		2				2					2	Member must use network providers.No copayment is required for covered Routine Physicals when provided in conjunction with an office visit. NOTE ON COPAYMENT: The member office visit copayment is $0.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Member must use network providers and can self-refer to a network PCP and OB/GYN.No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit.NOTE ON COPAYMENT: The member copayment is $0.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	
H4506	005	1	05	01	00001			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs. Prior authorization and referral is required for Disease Management.	1	00001			2						2				2	1		2				2	Member must use network providers.No separate copayment is required for covered Immunizations.  NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	1	2	1	3	1			2		2	1		2				2					2	Member must use network providers.No copayment is required for covered Routine Physicals when provided in conjunction with an office visit. NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Member must use network providers and can self-refer to a network PCP and OB/GYN.No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit.NOTE ON COPAYMENT: The member copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	
H4506	801	1	05	01	00001			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs. Prior authorization and referral is required for Disease Management.	1	00001			2						2				2	1		2				2	Member must use network providers.No separate copayment is required for covered Immunizations.  NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	1	2	1	3	1			2		2	1		2				2					2	Member must use network providers.No copayment is required for covered Routine Physicals when provided in conjunction with an office visit. NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Member must use network providers and can self-refer to a network PCP and OB/GYN.No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit.NOTE ON COPAYMENT: The member copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	
H4506	802	1	05	01	00001			2	2		2	2				0110000011	1																																				2																2		2			2					2	Member must use network providersMembers must meet clinical protocols to participate in Disease Management programs. SelectCare should be contacted for details. No prior authorization is required for Health Education/Wellness programs. Prior authorization and referral is required for Disease Management.	1	00001			2						2				2	1		2				2	Member must use network providers.No separate copayment is required for covered Immunizations.  NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	1	2	1	3	1			2		2	1		2				2					2	Member must use network providers.No copayment is required for covered Routine Physicals when provided in conjunction with an office visit. NOTE ON COPAYMENT: The member office visit copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	00001	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2	Member must use network providers and can self-refer to a network PCP and OB/GYN.No copayment is required for covered Pap Smears and Pelvic Exam Screenings when provided in conjunction with an office visit.NOTE ON COPAYMENT: The member copayment is $5.00 for a Primary Care Physician and $30.00 for a Specialty Care Physician.Authorization and referral is required ONLY when the covered services are provided by a non-Primary Care Physician.	1	
H4510	006	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$15 PCP$30 SPC	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $15 PCP $30 Specialist	2	
H4510	012	1	01	01	01000					1		1				0010000100	1																																				2																2		2			2					2	Member can receive health club membership and fitness classes through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$10 PCP$35 SPC	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						A copay may apply based on where the service is received.$10 PCP$35 Specialist	2	
H4510	015	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  For all other covered vaccines, a copay may apply based on where the service is received.$5 PCP$20 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Copay amount depends on setting where service is received: $5 PCP $20 SPC	2	
H4510	801	1	01	01	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. For all other covered vaccines, a copay may apply based on where the service is received.$25 PCP$35 Specialists	2	01000	1	1	2	1	3	1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Based on place of treatment, copays range as follows:$25 PCP$35 Specialists	2	
H4513	001	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if other services are received; but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN1 annual exam per year	2	
H4513	006	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if there are other services received, but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN.One annual visit per year.	2	
H4513	007	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	2		2				2	1 per year	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per year	2	
H4513	009	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if other services are received; but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN1 annual exam per year	2	
H4513	010	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if other services are received; but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN1 annual exam per year	2	
H4513	011	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if there are other services received, but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN.One annual visit per year.	2	
H4513	012	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	2		2				2	1 per year	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	1 exam per year	2	00110										2									2					2	3		2				2						Services must be obtained through network provider; 1 preventive exam per year	2	
H4513	013	1	01	01	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	The provider can charge an office copayment if other services are received; but there will not be a charge for the immunizations.	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	10100										2									2					2	3		2				2						Office visit copayment could apply; charges for procedure will be $0 copayment; services can be accessed through PCP or OB/GYN1 annual exam per year	2	
H4514	001	1	01	01	01000									1		1000000000	1																																				2																2		2			2	540.00	2		3	1	Plan offers a variety of health education and promotion services available through member's Care Coordinator including specialized assessments and care planning.Personal Healthcare BenefitAllows members to receive necessary healthcare items to address their specific needs.  This benefit covers items to support and/or improve conditions such as skin care, incontinence, pain management, mobility.  Member benefits are prorated based on date of enrollment with a maximum annual benefit of $450.  This benefit is classified in the ACR under category 13C.	2	10100			2						2				2	2		2				2	Includes Pneumococcal pneumonia vaccine, Flu vaccine, Hepatitis B vaccine (for people with Medicare who are at risk).	1	00100	1	1	2	1	3	1			2		2	2		2				2					2		1	00100										2									2					2	2		2				2						Limited to women with Medicare.	1	
H4590	010	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	01000			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H4590	012	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	01000			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H4590	013	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H4590	020	1	01	01	01000					1	1					0000000110	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit. Plan covers monthly membership fee for Silver Sneakers program through contracting service providers. No visit/use fees applicable to members at contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	1	1	2	1	3	1			2	0.00	1	2		2				2					2		2	00110	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	0.00	1	1		2				2					2	Section B -- 14d Pap/Pelvic -- Screen 1 -- Select enhanced benefits.  Members pay $0 for Pap Smear and Pelvic Exam annually or when medically necessary. No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists.  Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H4590	021	1	01	01	01000					1						0000000100	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers monthly membership fee for Silver Sneakers program through contracting service providers.  No visit/use fee's applicable to members at contracting service providers.	2	01000			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays the office visit copayment if other services are received.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H4590	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	001	1	01	01													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office visit cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	003	1	01	01													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office visit cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	008	2	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1							2																				01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	010	1	01	01													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office visit cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	011	1	01	01													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office visit cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	00110	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	00110										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5005	801	1	01	01													2																																																																	00110			2						2	0.00			1	1		2				2	Section B -- 14b Immunizations -- Screen 2 -- Is there an enrollee copayment.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2						Section B -- 14d Pap/Pelvic -- Screen 4 -- Is a referral required for Pap Smears and Pelvic Exams.  No referral necessary to Contracting Medical Group. Members have direct access to in-plan women's health specialists. Members pay physician office visit copay per self-referred visit with Contracting Medical Group.	2	2
H5006	001	1	09	04	01000			1			1					0000000011	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	You pay nothing for flu and pneumococcal immunizations; however, the office visit copay will apply if you receive other services at the time of the immunization.You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$30] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	01000	1	1	2	1	3	1			2		2	2		2				2	150.00	5	3	2	1	COVERAGE BASIS FOR MAXIMUM PLAN BENEFIT COVERAGE: Billed charge; paid up to benefit maximum .	2	01000										2									2					2	1		2				2						You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$30] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	
H5006	004	1	09	04	01000			1			1					0000000011	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	You pay nothing for flu and pneumococcal immunizations; however, the office visit copay will apply if you receive other services at the time of the immunization.You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$35] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	01000	1	1	2	1	3	1			2		2	2		2				2	150.00	5	3	2	1	COVERAGE BASIS FOR MAXIMUM PLAN BENEFIT COVERAGE: Billed charge; paid up to benefit maximum .	2	01000										2									2					2	1		2				2						You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$35] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	
H5006	005	1	09	04	01000			1			1					0000000011	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	You pay nothing for flu and pneumococcal immunizations; however, the office visit copay will apply if you receive other services at the time of the immunization.You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$35] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	01000	1	1	2	1	3	1			2		2	2		2				2	150.00	5	3	2	1	COVERAGE BASIS FOR MAXIMUM PLAN BENEFIT COVERAGE: Billed charge; paid up to benefit maximum .	2	01000										2									2					2	1		2				2						You pay [$15] for each primary care office visit for Medicare-covered services. If a provider is designated by Medicare as one of the following provider types: Family PracticePediatricsGeneral PracticeNurse PractitionerInternal MedicinePhysician AssistantObstetrics and GynecologyClinical Nurse SpecialistGeriatrics                                                 he/she will be considered as a primary care provider for Sterling Option I.You pay [$35] for each office visit if your provider's main area of practice is not classified as one of those listed above.	2	
H5050	001	1	02	01	01000					2					2	0000100100	1																																				2																2		2			2					2	BASE 1 - Enhanced Benefits:Member must use health club services and life time fitness programs at participating network facilities.Member must use M+CO approved tobacco cessation program.	2	00111	1	2	1						2				2	2		2				2	BASE 1- Enhanced Benefit:Immunizations and vaccines listed as covered in the M+CO formulary.	1	01000	2	1	2	1	2	1			2		2	2		2				2					2	BASE 3 - Authorization / Provider:Member must see plan contracted provider.	2	01000										2									2					2	1		2				2						BASE 4 - Separate Office Visit Cost Share / Copayment:A $10 copayment applies for each separate office visit cost share.BASE 4 - Authorization / Provider:Member must see plan contracted provider.	2	
H5050	002	1	02	01	01000					2					2	0000100100	1																																				2																2		2			2					2	BASE 1 - Enhanced Benefits:Member must use health club services and life time fitness programs at participating network facilities.Member must use M+CO approved tobacco cessation program.	2	00111	1	2	1						2				2	2		2				2	BASE 1- Enhanced Benefit:Immunizations and vaccines listed as covered in the M+CO formulary.	1	01000	2	1	2	1	2	1			2		2	2		2				2					2	BASE 3 - Authorization / Provider:Member must see plan contracted provider.	2	01000										2									2					2	1		2				2						BASE 4 - Separate Office Visit Cost Share / Copayment:A $10 copayment applies for each separate office visit cost share.BASE 4 - Authorization / Provider:Member must see plan contracted provider.	2	
H5050	004	1	02	01	01000					2					2	0000100100	1																																				2																2		2			2					2	BASE 1 - Enhanced Benefits:Member must use health club services and life time fitness programs at participating network facilities.Member must use M+CO approved tobacco cessation program.	2	00111	1	2	1						2				2	2		2				2	BASE 1- Enhanced Benefit:Immunizations and vaccines listed as covered in the M+CO formulary.	1	01000	2	1	2	1	2	1			2		2	2		2				2					2	BASE 3 - Authorization / Provider:Member must see plan contracted provider.	2	01000										2									2					2	1		2				2						BASE 4 - Separate Office Visit Cost Share / Copayment:A $10 copayment applies for each separate office visit cost share.BASE 4 - Authorization / Provider:Member must see plan contracted provider.	2	
H5050	005	2	02	01	01000					2					2	0000100100	1																																				2																2		2			2					2	BASE 1 - Enhanced Benefits:Member must use health club services and life time fitness programs at participating network facilities.Member must use M+CO approved tobacco cessation program.	2	00111	1	2	1						2				2	2		2				2	BASE 1- Enhanced Benefit:Immunizations and vaccines listed as covered in the M+CO formulary.	1	01000	2	1	2	1	2	1			2		2	2		2				2					2	BASE 3 - Authorization / Provider:Member must see plan contracted provider.	2	01000										2									2					2	1		2				2						BASE 4 - Separate Office Visit Cost Share / Copayment:A $10 copayment applies for each separate office visit cost share.BASE 4 - Authorization / Provider:Member must see plan contracted provider.	2	
H5050	006	2	02	01	01000					2					2	0000100100	1																																				2																2		2			2					2	BASE 1 - Enhanced Benefits:Member must use health club services and life time fitness programs at participating network facilities.Member must use M+CO approved tobacco cessation program.	2	00111	1	2	1						2				2	2		2				2	BASE 1- Enhanced Benefit:Immunizations and vaccines listed as covered in the M+CO formulary.	1	01000	2	1	2	1	2	1			2		2	2		2				2					2	BASE 3 - Authorization / Provider:Member must see plan contracted provider.	2	01000										2									2					2	1		2				2						BASE 4 - Separate Office Visit Cost Share / Copayment:A $10 copayment applies for each separate office visit cost share.BASE 4 - Authorization / Provider:Member must see plan contracted provider.	2	
H5149	801	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office vist may apply.	2	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2	A $20 copayment will apply if performed by a specialist.	2	00111		1	01		2		1		3	1									2					2	3		2				2					2	An office visit copayment may apply.	2	
H5151	002	1	01	01	00001		2	2				2	2		2	0011110001	1																																				2																2		2			2					2	Prior authorization applies to Nutritional Training, CHF and Disease Management.	2	01000			2						2				2	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	2	1	1			1			2	15.00	1	2		2				2					2		2	01000	2	2	11	1	1					1									2					2	1		2				2					2	Office visit copayment applies when being treated by aphysician for services that require copayment.only one copayment per date of service.	2	
H5151	801	1	01	01	00001		2	2				2	2		2	0011110001	1																																				2																2		2			2					2	Prior authorization applies to Nutritional Training, CHF and Disease Management.	2	01000			2						2				2	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	2	1	1			1			2	15.00	1	2		2				2					2		2	01000	2	2	11	1	1					1									2					2	1		2				2					2	Office visit copayment applies when being treated by aphysician for services that require copayment.only one copayment per date of service.	2	
H5211	001	1	02	01	01000			1	1		1	1		1	1	1110100011	1																																				2																2		2			2					2	Case Management Program is also offered.Some programs are targeted to at-risk individuals only.	2	01000	1	1	1						2				2	3		2				2	If an office visit is billed, $20 co-payment will apply.Other vaccines for those at risk (e.g, anti-rabies vaccine for those possibly exposed to rabies).	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed, $20 co-payment will apply.	2	
H5253	004	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H5253	006	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H5253	007	1	01	01	01000									1		1000000000	1																																				2																2		2			2					2	Evercare offers the following benefits within the nursing home:  Physician visitsNurse Practitioner visits and Family Counsels	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H5253	008	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H5262	001	1	01	01	01000				2		2	2				0110000010	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	If services are provided for the treatment of and existing or suspected condition and office visit copayment of $10 may apply.If an office visit is conducted in conjunction with these services a separate office visit copayment of $10 may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	If services are provided for the treatment of and existing or suspected condition and office visit copayment of $10 may apply.If an office visit is conducted in conjunction with these services a separate office visit copayment of $10 may apply.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	If services are provided for the treatment of and existing or suspected condition and office visit copayment of $10 may apply.If an office visit is conducted in conjunction with these services a separate office visit copayment of $10 may apply.	2	
H5402	001	1	01	01													2																																																																	00100			2						2				2	2		2				2		2	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	00100										2									2					2	2		2				2							2	
H5402	002	1	01	01													2																																																																	00100			2						2				2	2		2				2		2	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	00100										2									2					2	2		2				2							2	
H5402	006	1	01	01													2																																																																	00100			2						2				2	2		2				2		2	00100	1	1	2	1	3	1			2		2	2		2				2					2		2	00100										2									2					2	2		2				2							2	
H5404	001	1	01	01	01000		1	1				1	1		1	0011110001	1																																				2																2		2			2					2	No copayment is required for most services arranged through the Medicare Masterpiece Plan.  Appropriate Mental Health Copayment may apply.	2	00100			2	4			20		1				2	2		2				2	$0 copayment for Pneumonia and Flu vaccines.  Not referral necessary for Pneumonia and Flu vaccines.  You pay 20% of the cost for Hepatitis B vaccine.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H5404	002	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	No copayment is required for most services arranged through the Medicare Masterpiece Plan.  Appropriate Mental Health Copayment may apply.	2	00100			2	4			20		1				2	2		2				2	$0 copayment for Pneumonia and Flu vaccines.  Not referral necessary for Pneumonia and Flu vaccines.  You pay 20% of the cost for Hepatitis B vaccine.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H5404	003	1	01	01	01000		1	1	1			1	1		1	0111110001	1																																				2																2		2			2					2	No copayment is required for most services arranged through the Medicare Masterpiece Plan.  Appropriate Mental Health Copayment may apply.	2	00100			2	4			20		1				2	2		2				2	$0 copayment for Pneumonia and Flu vaccines.  Not referral necessary for Pneumonia and Flu vaccines.  You pay 20% of the cost for Hepatitis B vaccine.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H5404	004	1	01	01	01000		1	1				1	1		1	0011110001	1																																				2																2		2			2					2	No copayment is required for most services arranged through the Medicare Masterpiece Plan.  Appropriate Mental Health Copayment may apply.	2	00100			2	4			20		1				2	2		2				2	$0 copayment for Pneumonia and Flu vaccines.  Not referral necessary for Pneumonia and Flu vaccines.  You pay 20% of the cost for Hepatitis B vaccine.	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H5407	001	1	01	01	00101		1	1	1		1	1	1		1	0111110011	1																																				2																2		2			2	50.00	5		3	1	Health Education/Wellness Programs are open to all enrollees.  Specific goods and/or services may require a referral from the PCP or HMO.  CHC provides 2 in home visits per year as an additional benefit.	1	00100			2						2				2	2		2				2	There is a $30 co-payment for Hepatitis B vaccine when received outside of PCP office.	2	00100	1	1	2	1	3	1			2	0.00	1	2		2				2				1	1	Annual, routine physicals are considered a covered benefit when performed by the PCP	2	00100										2									2					2	2		2				2						$0 copay applies for services performed by the PCP.	2	
H9001	001	1	01	01	01000				2	2		2	2		2	0111100100	1																																				2						0.00	65.00	0.00	0.00		0.00	15.00			0.00	1		2			2					2	Members may pay a small amount, which varies by type of class and location. Other programs may also be available at other copayment amounts. Members must receive services from network providers. Contact plan for class listing.Smoking Cessation:Smoking Cessation classes are free. There is a small fee for anyone requesting the Nicotine patch or gum.Membership in Health Club/Fitness Classes:Members are eligible for the Silver Sneakers Fitness Program. This is a health and fitness program that provides access to contracted fitness facilities, allowing members use of amenities such as cardiovascular, strength and excercise equipment, and fitness classes (available amenities may vary slightly from facility to facility). Members do not have a copayment, coinsurance, or deductible for this program.	2	00110			2						2				2	1		2				2		2	01000	2	1	1			1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H9001	004	1	01	01	01000				2	2		2	2		2	0111100100	1																																				2						0.00	65.00	0.00	0.00		0.00	15.00			0.00	1		2			2					2	Members may pay a small amount, which varies by type of class and location. Other programs may also be available at other copayment amounts. Members must receive services from network providers. Contact plan for class listing.Smoking Cessation:Smoking Cessation classes are free. There is a small fee for anyone requesting the Nicotine patch or gum.Membership in Health Club/Fitness Classes:Members are eligible for the Silver Sneakers Fitness Program. This is a health and fitness program that provides access to contracted fitness facilities, allowing members use of amenities such as cardiovascular, strength and excercise equipment, and fitness classes (available amenities may vary slightly from facility to facility). Members do not have a copayment, coinsurance, or deductible for this program.	2	00110			2						2				2	1		2				2		2	01000	2	1	1			1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H9001	006	1	01	01	01000				2	2		2	2		2	0111100100	1																																				2						0.00	65.00	0.00	0.00		0.00	10.00			0.00	1		2			2					2	Members may pay a small amount, which varies by type of class and location. Other programs may also be available at other copayment amounts. Members must receive services from network providers. Contact plan for class listing.Smoking Cessation:Smoking Cessation classes are free. There is a small fee for anyone requesting the Nicotine patch or gum.Membership in Health Club/Fitness Classes:Members are eligible for the Silver Sneakers Fitness Program. This is a health and fitness program that provides access to contracted fitness facilities, allowing members use of amenities such as cardiovascular, strength and excercise equipment, and fitness classes (available amenities may vary slightly from facility to facility). Members do not have a copayment, coinsurance, or deductible for this program.	2	00110			2						2				2	1		2				2		2	01000	2	1	1			1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H9001	007	1	01	01	01000				2	2		2	2		2	0111100100	1																																				2						0.00	65.00	0.00	0.00		0.00	10.00			0.00	1		2			2					2	Members may pay a small amount, which varies by type of class and location. Other programs may also be available at other copayment amounts. Members must receive services from network providers. Contact plan for class listing.Smoking Cessation:Smoking Cessation classes are free. There is a small fee for anyone requesting the Nicotine patch or gum.Membership in Health Club/Fitness Classes:Members are eligible for the Silver Sneakers Fitness Program. This is a health and fitness program that provides access to contracted fitness facilities, allowing members use of amenities such as cardiovascular, strength and excercise equipment, and fitness classes (available amenities may vary slightly from facility to facility). Members do not have a copayment, coinsurance, or deductible for this program.	2	00110			2						2				2	1		2				2		2	01000	2	1	1			1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H9003	001	1	01	01	00110			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, everal classes in disease management, class and phone-based smoking cessation, a pain mgmt program, online health assessment, information in medical and drug encyclopedias and health Education resource center with a large inventory of books and videos on a multitude of health issues. Cost for health education classes and programs vary. Members pay no membership fees or monthly dues for health club membership at participating fitness facilities. Location of fitness facilities may vary. Contact KP for details.Some disease management and other classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	immunizations for travel are covered. If immunizations are given as part of a physician office visit, the office visit copayment applies.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9003	002	1	01	01	00110			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, everal classes in disease management, class and phone-based smoking cessation, a pain mgmt program, online health assessment, information in medical and drug encyclopedias and health Education resource center with a large inventory of books and videos on a multitude of health issues. Cost for health education classes and programs vary. Members pay no membership fees or monthly dues for health club membership at participating fitness facilities. Location of fitness facilities may vary. Contact KP for details.Some disease management and other classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	immunizations for travel are covered. If immunizations are given as part of a physician office visit, the office visit copayment applies.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9003	003	2	01	01	00110			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, everal classes in disease management, class and phone-based smoking cessation, a pain mgmt program, online health assessment, information in medical and drug encyclopedias and health Education resource center with a large inventory of books and videos on a multitude of health issues. Cost for health education classes and programs vary. Members pay no membership fees or monthly dues for health club membership at participating fitness facilities. Location of fitness facilities may vary. Contact KP for details.Some disease management and other classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	immunizations for travel are covered. If immunizations are given as part of a physician office visit, the office visit copayment applies.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9003	005	1	01	01	00110			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, everal classes in disease management, class and phone-based smoking cessation, a pain mgmt program, online health assessment, information in medical and drug encyclopedias and health Education resource center with a large inventory of books and videos on a multitude of health issues. Cost for health education classes and programs vary. Members pay no membership fees or monthly dues for health club membership at participating fitness facilities. Location of fitness facilities may vary. Contact KP for details.Some disease management and other classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	immunizations for travel are covered. If immunizations are given as part of a physician office visit, the office visit copayment applies.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9003	801	1	01	01	00110			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	Kp offers several weight management programs, several classes in disease management, class and phone-based smoking cessation, a pain management program, online health assessment, information in medical and drug encyclopedias and heath education resource center with a large inventory of books and videos on a multitude of health issues. Cost for health education classes and programs vary. Members pay no membership fees or monthly dues for health clusm membership at participating facilities. Location of fitness facilities may vary. Contact KP for details. Some disease management and other classes require physician or provider referral	1	00110	1	2	1						2				2	3		2				2	immunizations for travel are covered. If immunizations are given as part of a physician office visit, the office visit copayment applies.	1	01000	2	1	2	1	2	1			2	30.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.	2	01000										2									2	0.00	30.00			1	2		2				2							2	2
H9005	004	1	01	01	00110		2	2	2		2	2	2		2	0111110011	1																																				2			0.00	0.00	10.00	0.00	10.00			0.00	0.00	0.00			0.00	1		2			2					2	Some health education is provided at no charge - others have a nominal feelOffice visit copayment may apply.	1	00110	1	2	1						2				2	2		2				2	Tetanus-diptheria immuniztion every 10 years.Office visit copayment may apply.	1	00100	2	1	1			1			2		2	2		2				2					2	A physician or health care provider will counsel members as to how often health assessments are needed based on age, sex and health status of the member.	2	01000										2									2					2	2		2				2						Members may self-refer to an Ob/Gyn within the network.Office visit copayment may apply.	2	
H9011	003	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	2		2				2	No copayment for Influenza and Pneumococcal vaccinations.	2	01000	1	1	1			1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H9011	009	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	2		2				2	No copayment for Influenza and Pneumococcal vaccinations. F	2	01000	1	1	1			1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H9011	010	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	2		2				2	No copayment for Influenza and Pneumococcal vaccinations.	2	01000	1	1	1			1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H9011	011	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	2		2				2	No copayment for Influenza and Pneumococcal vaccinations. F	2	01000	1	1	1			1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H9011	801	1	01	01	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS:  Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate.  Contact us for details.Members must meet clinical protocol to participate in disease management programs-- contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.	2	01000			2						2				2	3		2				2	No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.	2	01000	1	1	2	1	3	1			2	30.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.	2	
H9016	002	1	01	01													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H9016	004	2	01	01													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H9016	006	1	01	01													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H9047	001	1	01	01	01000		1	1			1	1	1	1	1	1011110011	1				6	6			6	6	6	6	6									0	0			0			0		0	0	0	0	0		1																2		2			2	350.00	6		3	1	#14a Health Ed/Wellness 1, Select Enhanced Benefit: Base 2Indicate Maximum Plan Benefit Coverage Amount: $350.00We offer the following Health Education classes, allowing a total annual benefit of $350.00 per year. Beneificiaires may receive these services on a self-referral basis at any participating hopsital. Providence Helath Plan will pay for the following classes, up to:-$125.00 for Nutritional Training -$160.00 for Smoking Cessation -$65.00 for Child Birth ClassesThe following programs are offered at no additional charge to beneficiaries: Congestive Heart Failure (CHF) Program Rare Disease Management Program- End Stage Renal Disease ProgramCoronary Artery Disease (CAD) ProgramDiabetic Quarterly Newsletter Nursing Hotline Newsletters	2	00101	1	1	1						2				2	3		2				2	#14b Immunizations Base 1Select Enchanced benefit: Other Immunizations, describe:Coverage is provided for:Diptheria/TetanusPolioMealses, Mumps and RubellaChicken PoxGamma GlobulinOther, if exposed to a specific diseaseCoverage is not provided forimmunization(s) for foreign travel.Base 2Indicate whether a separate office visit cost share applies for services: Sometimes, describe:Office visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a flu shot during the course of an annual physical, no copayment would apply to the flu shot. However, the office visit copayment for the physical itself would apply.Base 3NOTE: No referral is needed as long as the Immunizations are administered by the Primary Care Physician or Network Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	3		2				2					2	#14c Routine Physicial Base 1Number Of Visits Periodically: One every yearOnce every year is equal to once every 12 months. Members are required to obtain Routine Physical Examinations through their Primary Care Physician.	2	00101	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	#14d Pap/Pelvic Base 3I ndicate whether a separate office visit cost share applies for services:Sometimes, describeOffice visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a pelvic exam during the course of an annual physical, no copayment would apply to the pelvic exam. However, the office visit copayment for the physical itself would apply.	2	
H9047	013	2	01	01	01000		1	1			1	1	1	1	1	1011110011	1				6	6			6	6	6	6	6									0	0			0			0		0	0	0	0	0		1																2		2			2	350.00	6		3	1	#14a Health Ed/Wellness 1, Select Enhanced Benefit: Base 2Indicate Maximum Plan Benefit Coverage Amount: $350.00We offer the following Health Education classes, allowing a total annual benefit of $350.00 per year. Beneificiaires may receive these services on a self-referral basis at any participating hopsital. Providence Helath Plan will pay for the following classes, up to:-$125.00 for Nutritional Training -$160.00 for Smoking Cessation -$65.00 for Child Birth ClassesThe following programs are offered at no additional charge to beneficiaries: Congestive Heart Failure (CHF) Program Rare Disease Management Program- End Stage Renal Disease ProgramCoronary Artery Disease (CAD) ProgramDiabetic Quarterly Newsletter Nursing Hotline Newsletters	2	00101	1	1	1						2				2	3		2				2	#14b Immunizations Base 1Select Enchanced benefit: Other Immunizations, describe:Coverage is provided for:Diptheria/TetanusPolioMealses, Mumps and RubellaChicken PoxGamma GlobulinOther, if exposed to a specific diseaseCoverage is not provided forimmunization(s) for foreign travel.Base 2Indicate whether a separate office visit cost share applies for services: Sometimes, describe:Office visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a flu shot during the course of an annual physical, no copayment would apply to the flu shot. However, the office visit copayment for the physical itself would apply.Base 3NOTE: No referral is needed as long as the Immunizations are administered by the Primary Care Physician or Network Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	3		2				2					2	#14c Routine Physicial Base 1Number Of Visits Periodically: One every yearOnce every year is equal to once every 12 months. Members are required to obtain Routine Physical Examinations through their Primary Care Physician.	2	00101	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	#14d Pap/Pelvic Base 3I ndicate whether a separate office visit cost share applies for services:Sometimes, describeOffice visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a pelvic exam during the course of an annual physical, no copayment would apply to the pelvic exam. However, the office visit copayment for the physical itself would apply.	2	
H9047	022	1	01	01	01000		1	1			1	1	1	1	1	1011110011	1				6	6			6	6	6	6	6									0	0			0			0		0	0	0	0	0		1																2		2			2	350.00	6		3	1	#14a Health Ed/Wellness 1, Select Enhanced Benefit: Base 2Indicate Maximum Plan Benefit Coverage Amount: $350.00We offer the following Health Education classes, allowing a total annual benefit of $350.00 per year. Beneificiaires may receive these services on a self-referral basis at any participating hopsital. Providence Helath Plan will pay for the following classes, up to:-$125.00 for Nutritional Training -$160.00 for Smoking Cessation -$65.00 for Child Birth ClassesThe following programs are offered at no additional charge to beneficiaries: Congestive Heart Failure (CHF) Program Rare Disease Management Program- End Stage Renal Disease ProgramCoronary Artery Disease (CAD) ProgramDiabetic Quarterly Newsletter Nursing Hotline Newsletters	2	00101	1	1	1						2				2	3		2				2	#14b Immunizations Base 1Select Enchanced benefit: Other Immunizations, describe:Coverage is provided for:Diptheria/TetanusPolioMealses, Mumps and RubellaChicken PoxGamma GlobulinOther, if exposed to a specific diseaseCoverage is not provided forimmunization(s) for foreign travel.Base 2Indicate whether a separate office visit cost share applies for services: Sometimes, describe:Office visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a flu shot during the course of an annual physical, no copayment would apply to the flu shot. However, the office visit copayment for the physical itself would apply.Base 3NOTE: No referral is needed as long as the Immunizations are administered by the Primary Care Physician or Network Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	3		2				2					2	#14c Routine Physicial Base 1Number Of Visits Periodically: One every yearOnce every year is equal to once every 12 months. Members are required to obtain Routine Physical Examinations through their Primary Care Physician.	2	00101	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	#14d Pap/Pelvic Base 3I ndicate whether a separate office visit cost share applies for services:Sometimes, describeOffice visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a pelvic exam during the course of an annual physical, no copayment would apply to the pelvic exam. However, the office visit copayment for the physical itself would apply.	2	
H9047	024	1	01	01	01000		1	1			1	1	1	1	1	1011110011	1				6	6			6	6	6	6	6									0	0			0			0		0	0	0	0	0		1																2		2			2	350.00	6		3	1	#14a Health Ed/Wellness 1, Select Enhanced Benefit: Base 2Indicate Maximum Plan Benefit Coverage Amount: $350.00We offer the following Health Education classes, allowing a total annual benefit of $350.00 per year. Beneificiaires may receive these services on a self-referral basis at any participating hopsital. Providence Helath Plan will pay for the following classes, up to:-$125.00 for Nutritional Training -$160.00 for Smoking Cessation -$65.00 for Child Birth ClassesThe following programs are offered at no additional charge to beneficiaries: Congestive Heart Failure (CHF) Program Rare Disease Management Program- End Stage Renal Disease ProgramCoronary Artery Disease (CAD) ProgramDiabetic Quarterly Newsletter Nursing Hotline Newsletters	2	00101	1	1	1						2				2	3		2				2	#14b Immunizations Base 1Select Enchanced benefit: Other Immunizations, describe:Coverage is provided for:Diptheria/TetanusPolioMealses, Mumps and RubellaChicken PoxGamma GlobulinOther, if exposed to a specific diseaseCoverage is not provided forimmunization(s) for foreign travel.Base 2Indicate whether a separate office visit cost share applies for services: Sometimes, describe:Office visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a flu shot during the course of an annual physical, no copayment would apply to the flu shot. However, the office visit copayment for the physical itself would apply.Base 3NOTE: No referral is needed as long as the Immunizations are administered by the Primary Care Physician or Network Specialist	2	01000	1	1	2	1	3	1			2	20.00	1	3		2				2					2	#14c Routine Physicial Base 1Number Of Visits Periodically: One every yearOnce every year is equal to once every 12 months. Members are required to obtain Routine Physical Examinations through their Primary Care Physician.	2	00101	1	1	11	2	2	1	1	3	3	1	2	2	2	2	10	10	10	10	1					2	3		2				2					2	#14d Pap/Pelvic Base 3I ndicate whether a separate office visit cost share applies for services:Sometimes, describeOffice visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a pelvic exam during the course of an annual physical, no copayment would apply to the pelvic exam. However, the office visit copayment for the physical itself would apply.	2	2
H9047	801	1	01	01	01000		1	1			1	1	1	1	1	1011110011	1				6	6			6	6	6	6	6									0	0			0			0		0	0	0	0	0		1																2		2			2	350.00	6		3	1	#14a Health Ed/Wellness 1, Select Enhanced Benefit: Base 2Indicate Maximum Plan Benefit Coverage Amount: $350.00We offer the following Health Education classes, allowing a total annual benefit of $350.00 per year. Beneificiaires may receive these services on a self-referral basis at any participating hopsital. Providence Helath Plan will pay for the following classes, up to:-$125.00 for Nutritional Training -$160.00 for Smoking Cessation -$65.00 for Child Birth ClassesThe following programs are offered at no additional charge to beneficiaries: Congestive Heart Failure (CHF) Program Rare Disease Management Program- End Stage Renal Disease ProgramCoronary Artery Disease (CAD) ProgramDiabetic Quarterly Newsletter Nursing Hotline Newsletters	2	00101	1	1	1						2				2	3		2				2	#14b Immunizations Base 1Select Enchanced benefit: Other Immunizations, describe:Coverage is provided for:Diptheria/TetanusPolioMealses, Mumps and RubellaChicken PoxGamma GlobulinOther, if exposed to a specific diseaseCoverage is not provided forimmunization(s) for foreign travel.Base 2Indicate whether a separate office visit cost share applies for services: Sometimes, describe:Office visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a flu shot during the course of an annual physical, no copayment would apply to the flu shot. However, the office visit copayment for the physical itself would apply.Base 3NOTE: No referral is needed as long as the Immunizations are administered by the Primary Care Physician or Network Specialist	2	01000	1	1	2	1	3	1			2	15.00	1	3		2				2					2	#14c Routine Physicial Base 1Number Of Visits Periodically: One every yearOnce every year is equal to once every 12 months. Members are required to obtain Routine Physical Examinations through their Primary Care Physician.	2	00101	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	#14d Pap/Pelvic Base 3I ndicate whether a separate office visit cost share applies for services:Sometimes, describeOffice visit copayment may apply (see Health Care Professional Services and Preventive Services for applicable copayments). For example, if a member has a pelvic exam during the course of an annual physical, no copayment would apply to the pelvic exam. However, the office visit copayment for the physical itself would apply.	2	
H9049	001	1	01	01	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed, a copayment will apply.	2	
H0102	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H0103	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	12.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H0313	001	1	26	05	01000				1		1					0100000010	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers membership fee for Silver Sneakers Steps program through contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers CareWise 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	01000			2	5			10		1				2	1	100.00	1				2	Section B -- 14b Immunizations -- Screen 1 -- Select the Coinsurance Coverage Basis for Medicare Covered Benefits - Hepatitis B.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	01000	1	1	2	1	3	1			2	10.00	1	2	100.00	1				2	300.00	5	3	2	1	Section B -- 14c Routine Phys -- Screen 2 -- Select the Coverage Basis for Maximum Plan Benefit Coverage.  Limit is based upon PacifiCare's contractually negotiated rates; if not available, limit is based on Medicare Allowable Cost (MAC).	2	01000										2	5	5			0	10			1					2	1	100.00	1				2						Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pap Smears.  Enrollees pay nothing for pap smears.  Coinsurance applies to pelvic exam.Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pelvic Exams.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	2
H0313	002	1	26	05	01000				1		1					0100000010	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers membership fee for Silver Sneakers Steps program through contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers CareWise 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	01000			2	5			10		1				2	1	100.00	1				2	Section B -- 14b Immunizations -- Screen 1 -- Select the Coinsurance Coverage Basis for Medicare Covered Benefits - Hepatitis B.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	01000	1	1	2	1	3	1			2	10.00	1	2	100.00	1				2	300.00	5	3	2	1	Section B -- 14c Routine Phys -- Screen 2 -- Select the Coverage Basis for Maximum Plan Benefit Coverage.  Limit is based upon PacifiCare's contractually negotiated rates; if not available, limit is based on Medicare Allowable Cost (MAC).	2	01000										2	5	5			0	10			1					2	1	100.00	1				2						Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pap Smears.  Enrollees pay nothing for pap smears.  Coinsurance applies to pelvic exam.Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pelvic Exams.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	2
H0314	001	1	26	05	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	IN-NETWORK: $0.  Health Club Membership at Health Net contracted facilities only.OUT-OF-NETWORK: Not covered.	2	00111	1	2	1						2				2	1		2				2	IN-NETWORK: $0 for the flu and pneumonia vaccines. However, a doctor office visit copayment will apply if enrollee receives other services at the same visit.Other immunizations covered: Tetanus.OUT-OF-NETWORK: Not covered.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	IN-NETWORK: $10OUT-OF-NETWORK: Not covered.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	IN-NETWORK: $0 for the Medicare-covered service.  However, copayments are applied as appropriate depending on the place of service.OUT-OF-NETWORK: Not covered.	2	
H0314	002	1	26	05	01000			2	2	2	2				2	0100100111	1																																				2																2		2			2					2	IN-NETWORK: $0.  Health Club Membership at Health Net contracted facilities only.OUT-OF-NETWORK: Not covered.	2	00111	1	2	1						2				2	1		2				2	IN-NETWORK: $0 for the flu and pneumonia vaccines. However, a doctor office visit copayment will apply if enrollee receives other services at the same visit.Other immunizations covered: Tetanus.OUT-OF-NETWORK: Not covered.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	IN-NETWORK: $10OUT-OF-NETWORK: Not covered.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	IN-NETWORK: $0 for the Medicare-covered service.  However, copayments are applied as appropriate depending on the place of service.OUT-OF-NETWORK: Not covered.	2	
H0314	003	1	26	05	01000			2	2		2				2	0100100011	1																																				2																2		2			2					2	IN-NETWORK: $0. OUT-OF-NETWORK: Not covered.	2	00111	1	2	1						2				2	1		2				2	IN-NETWORK: $0 for the flu and pneumonia vaccines. However, a doctor office visit copayment will apply if enrollee receives other services at the same visit.Other immunizations covered: Tetanus.OUT-OF-NETWORK: Not covered.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	IN-NETWORK: $10OUT-OF-NETWORK: Not covered.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	IN-NETWORK: $0 for the Medicare-covered service.  However, copayments are applied as appropriate depending on the place of service.OUT-OF-NETWORK: Not covered.	2	
H0314	004	1	26	05	01000			2	2		2				2	0100100011	1																																				2																2		2			2					2	IN-NETWORK: $0. OUT-OF-NETWORK: Not covered.	2	00111	1	2	1						2				2	1		2				2	IN-NETWORK: $0 for the flu and pneumonia vaccines. However, a doctor office visit copayment will apply if enrollee receives other services at the same visit.Other immunizations covered: Tetanus.OUT-OF-NETWORK: Not covered.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2	IN-NETWORK: $10OUT-OF-NETWORK: Not covered.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	IN-NETWORK: $0 for the Medicare-covered service.  However, copayments are applied as appropriate depending on the place of service.OUT-OF-NETWORK: Not covered.	2	
H0357	001	1	14	05													2																																																															Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).		01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H0502	001	1	18	06	01000	1		1	1		1	1	1		1	0111101011	1																																				2																2		2			2					2	Referral required to attend most health education classes at CCRMC.	1	01000	1	1	1						2				2	2		2				2	Hepatitis B vaccine covered at no cost for beneficiaries who are at risk.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2	You must use network providers.	2	01000	1	1	11	1	1					1									2					2	2		2				2					2	You must use network providers.	2	
H0502	002	1	18	06	00001	1		1	1		1	1	1		1	0111101011	1																																				2																2		2			2					2	Referral required to attend most health education classes at CCRMC.	1	00001	1	1	1						2				2	2		2				2	Hepatitis B vaccine covered at no cost for beneficiaries who are at risk.	1	01000	1	1	2	1	3	1			2		2	2		2				2	1.00	4	3	2	1		2	01000	1	1	11	1	1					1									2					2	2		2				2					2	You must use network providers.	2	
H0602	001	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	002	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	0.00	0.00	15.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	003	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	004	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	005	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	006	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	007	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	008	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	15.00	0.00	15.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0602	009	1	18	06	01000			1				1		1		1010000001	1																																				2																2		2			2					2	Step CountersStep counters are sent to new members upon enrollment.Step counters are sent to renewing members, upon request, every third year thereafter.	2	01000			2						2				2	3		2				2	Office visit copayment may apply, if billed by the physician.	2	01000	1	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	Office visit Copayment my apply, if billed by the physician.	2	2
H0619	001	1	22	05													2																																																																	00110			2						2	0.00			1	3		2				2	Section B -- 14b Immunizations -- Screen 2 -- Indicate whether a separate office vist cost share applies for services.  Member pays nothing for Hepatitis B vaccine, Flu vaccine and pneumococcal pneumonia vaccine. No referral needed for flu vaccine.  Member pays only the office visit copayment if other services are received.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2	0.00	0.00			1	1		2				2							2	2
H0662	001	1	14	05													2																																																															Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).		01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H0706	001	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H0706	801	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H0706	802	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H1047	001	1	26	05	01000					1		1				0010000100	1																																				2																2		2			2					2	Members can receive health club membership through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  All other covered vaccines, a copay may apply based on the setting where the service is received::$5 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						A copay may apply based on the setting where the service is received:* $5 PCP* $25 Specialist	2	
H1047	002	1	26	05	01000					1		1				0010000100	1																																				2																2		2			2					2	Members can receive health club membership through the Silver Sneakers Fitness Program.	2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine.  All other covered vaccines, a copay may apply based on the setting where the service is received::$5 PCP$25 Specialist	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						A copay may apply based on the setting where the service is received:* $5 PCP* $25 Specialist	2	
H1083	001	1	14	05	01000									1		1000000000	1																																				2																2		2			2	240.00	2		3	1	Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).Personal Healthcare BenefitAllows members to receive necessary healthcare items to address their specific needs.  This benefit covers items to support and/or improve conditions such as skin care, incontinence, pain management, mobility.  Member benefits are prorated based on date of enrollment with a maximum annual benefit of $200.   This benefit is classified in the ACR under category 13C.	2	01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H1083	002	1	14	05	01000									1		1000000000	1																																				2																2		2			2	240.00	2		3	1	Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).Personal Healthcare BenefitAllows members to receive necessary healthcare items to address their specific needs.  This benefit covers items to support and/or improve conditions such as skin care, incontinence, pain management, mobility.  Member benefits are prorated based on date of enrollment with a maximum annual benefit of $200.  This benefit is classified in the ACR under category 13C.	2	01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H1151	001	1	14	05													2																																																															Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).		01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H1251	001	1	18	06	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000			2						2				2	1		2				2		2							2																				01000										2									2					2	1		2				2							2	
H1251	002	1	18	06	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000			2						2				2	1		2				2		2							2																				01000										2									2					2	1		2				2							2	
H1251	003	1	18	06	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000			2						2				2	1		2				2		2							2																				01000										2									2					2	1		2				2							2	
H1349	001	1	18	06													2																																																																	01000			2						2				2	3		2				2	Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	2							2																				01000										2									2					2	3		2				2						Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	1	
H1349	006	1	18	06													2																																																																	01000			2						2				2	3		2				2	Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	2	00100	2	1	1			1			2	10.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	1	
H1349	008	2	18	06													2																																																																	01000			2						2				2	3		2				2	Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	2							2																				01000										2									2					2	3		2				2						Seperate office copayments of $10.00 will be charged if services are in conjunction with an office call.	1	
H1349	010	1	18	06													2																																																																	01000			2						2				2	3		2				2	Seperate office copayments of $20.00 will be charged if services are in conjunction with an office call.	2							2																				01000										2									2					2	3		2				2						Seperate office copayments of $20.00 will be charged if services are in conjunction with an office call.	1	
H1407	001	1	24	05	01000							1				0010000000	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	There is no copay when office visit is specific for flu vaccine and pneumonia vaccine. All other covered vaccines, a copay may apply based on the setting where the service is received:* $5 PCP* $25 Specialist	2							2																				01000										2									2					2	1		2				2						A copay may apply based on the setting the service is received:* $5 PCP* $25 Specialist	2	
H1408	001	1	26	05	01000		1	1	1			1	1	1	1	1111110001	1																																				2			0.00	0.00	0.00	0.00	10.00				0.00	10.00	0.00	10.00	0.00	1		2			2					2	Additional programs include diabetes awareness/wellness programs, pnuemoccal/flu shot education, colorectal screening awareness, mammography awareness, etc.  Scales are covered one time for CHF patients identified as appropriate through a disease management program.	2	01000	1	1	1						2	10.00	10.00	10.00	1	3		2				2	The only time a separate office visit cost share applies is if the immunization is secondary to a primary treatment for which the office visit occured.  Tetanus shots covered every 10 years or as medically indicated.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2		2	01000		1	01		2		1		3	1									2					2	1		2				2					2		2	
H1412	001	1	26	05	01000									2		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	2	01000			2						2				2	3		2				2	Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H1412	801	1	26	05	01000									2		1000000000	1																																				2																2		2			2					2	Section B, #14a Health Education / Wellness:Health education programs include; Health Education classes, Member newsletter, Congestive heart program, Disease management, Total Joint Replacement, Diabetes, and Chronic Obstructive Pulmonary Disease management.	2	01000			2						2				2	3		2				2	Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						Section B, #14d:Office visit copay may apply.	2	
H1413	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H1472	001	1	18	06	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	PBP 2003 noted that Member pays $0 for exam, but $10 for doctor office visit.  Please note the following clarification made to the PBP 2004.Because a member cannot have a routine physical without seeing his/her physician and only one exam code is billed, it is more clear to state that there is a  copayment but no separate office visit copayment for routine physicals.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H1472	002	1	18	06	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2		2	01000	1	1	1						2				2	1		2				2	No referral necessary for network providers.  No copayment for the vaccine, but separate doctor office visit copayment applies if seen by the physician.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	PBP 2003 noted that Member pays $0 for exam, but $10 for doctor office visit.  Please note the following clarification made to the PBP 2004.Because a member cannot have a routine physical without seeing his/her physician and only one exam code is billed, it is more clear to state that there is a  copayment but no separate office visit copayment for routine physicals.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	1		2				2					2	No referral necessary for network providers.Coverage limited to one pap smear and one pelvic exam each year.No copayment for pap smear or pelvic exam, but separate doctor office copayment applies.	2	
H1508	001	1	26	05	01000		1	1	1		1	1			1	0110110011	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1508	801	1	26	05	01000		1	1	1		1	1			1	0110110011	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	2		2				2							2	
H1555	001	2	18	06													2																																																																	00001			2						2	0.00			1	2		2				2		1							2																				00001										2									2	0.00	0.00			1	2		2				2							1	2
H1555	002	2	18	06													2																																																																	00001			2						2	0.00			1	2		2				2		1	01000	1	1	1			1			2	0.00	1	2		2				2					2		2	00001										2									2	0.00	0.00			1	2		2				2							1	2
H1555	003	2	18	06													2																																																																	00001			2						2	0.00			1	2		2				2		1	01000	1	1	1			1			2	0.00	1	2		2				2					2		2	00001										2									2	0.00	0.00			1	2		2				2							1	2
H1558	003	1	18	06	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2							2																				01000										2									2					2	2		2				2							2	
H1558	004	1	18	06	01000			1	1			1				0110000001	1																																				2																2		2			2					2		2	00110			2						2				2	2		2				2		1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H1558	005	2	18	06	00111		1	1	1			1				0110010001	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2							2																				01000										2									2					2	2		2				2							2	
H1651	001	1	18	06													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	2		2				2					2		2	
H1651	002	1	18	06													2																																																																	01000			2						2				2	2		2				2		2							2																				01000										2									2					2	2		2				2							2	
H1651	003	1	18	06													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	2		2				2					2		2	
H1715	001	1	26	05	00001		1	1	1		1	1				0110010011	1																																				2																2		2			2					2	The plan covers a variety of services.  Ask Advantra for more details.Members Choice (SM) offers access to a wide variety of complementary services to help members lead a healthier lifestyle.  The program is offered through a relationship with American Specialty Health Networks (ASHN) and Healthyroads.	2	01000	1	1	1						2				2	3		2				2	Office visit copayment may apply.$0 copayment for Pneumococcal pneumonia vaccine and flu vaccines.$0 copayment for Hepatitis B vaccineFor flu shots and pneumonia vaccines, you can self-refer to a network provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	$20 copayment may apply when services are performed by a specialist.	2	01000		1	01		2		1		3	1									2					2	3		2				2					2	No referral necessary for network providers.Doctor office visit copayment may apply when you are treated for illnesses that are not related to your preventive care during the same visit.	2	
H1805	001	1	26	05													2																																																																	01000			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H1901	001	1	26	05	01000		1	1	1	1	1	1	1			0111010111	1																																				2																2		2			2					2		2	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	1	1					1									2					2	2		2				2					2		2	
H2110	001	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H2110	801	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H2110	802	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H2150	002	1	18	06	01000	2	2	2	2		2	2	2		2	0111111011	1																																				2	10.00	10.00	0.00	0.00	79.00	0.00	79.00			0.00	0.00	15.00			0.00	1		2			2					2		2	00100			2						2	15.00			1	2		2				2		1	00100	2	1	2	1	3	1			2	15.00	1	2		2				2					2		1	01000										2									2	15.00	15.00			1	2		2				2							2	2
H2155	001	1	14	05	01000									1		1000000000	1																																				2																2		2			2	240.00	2		3	1	Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).Personal Healthcare BenefitAllows members to receive necessary healthcare items to address their specific needs.  This benefit covers items to support and/or improve conditions such as skin care, incontinence, pain management, mobility.  Member benefits are prorated based on date of enrollment with a maximum annual benefit of $200.  This benefit is classified in the ACR under category 13C.Up & Go ProgramThe Up & Go program is a supervised walking program designed to keep the enrollee active and moving.This program is focused on individuals that are currently walking and at risk for the loss of that activity. The individuals that participate in this program will need to be able to follow direction by a PTA (Physical Therapy Aide) for a period of 30 minutes 3 times per week. An initial evaluation will determine if the enrollee meets the criteria and periodic assessments will be done to ensure the enrollee continues to benefit from the program.Therapy aide will provide services at a ratio of two enrollees to one aide.	2	01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H2259	001	1	14	05													2																																																															Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).		01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H2259	004	1	14	05													2																																																															Evercare offers the following benefits within the nursing home: Physician visits, Nurse Practitioner visits, and Family counsels.Authorization is co-ordinated through the Primary Care Team (Nurse Practitioner and Primary Care Physician).		01000			2						2				2	2		2				2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100	1	1	2	1	3	1			2		2	2		2				2					2	Primary Care Team: nurse Practitioner and Primary Care Physician	1	00100										2									2					2	2		2				2						Primary Care Team: nurse Practitioner and Primary Care Physician	1	
H2407	001	1	16	05																																																																																																																																																																						
H2450	001	1	18	06	01000				1	3	1	1			1	0110100110	1						7	7	7	7			7											0			0	0		0	0	0			20		1																2		2			2					2	smoking cessation drugs and other smoking cessation over the counter aids available under pharmacy rider silver sneaker /walksport available as a no cost rider at specific fitness facilities within service area	2	01000	1	1	1						2				2	3		2				2	office copay could apply if member is being seen for other medical conditionTetanus immunization covered once every ten years	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	office visit copay could apply if physican is checking on a pre-exisiting medical condition during physical. Example member has diabetes	2	01000	1	1	11	2	2	1	1	6	6	1									2					2	3		2				2					2	additional papsmears/pelvic exams - as medically necessary /1 per year	2	
H2450	002	1	18	06	01000				1	3	1	1			3	0110100110	1																																				2																2		2			2					2	smoking cessation drugs and other smoking cessation over thr counter aids are available under the pharmacy rider silver sneakers/walksport available as a no cost rider at specific fitness facilities within service area.	2	01000	1	1	1						2				2	2		2				2	plan covers tetanus booster within recommended guidelines	2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000	1	1	11	2	2	1	1	3	3	1									2					2	2		2				2					2		2	
H2456	002	1	16	05																																																																																																																																																																						
H2457	002	1	16	05																																																																																																																																																																						
H2458	002	1	16	05																																																																																																																																																																						
H2903	001	1	26	05	01000				1		1					0100000010	1																																				2																2		2			2					2	Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan covers membership fee for Silver Sneakers Steps program through contracting service providers.Section B -- 14a Health Ed/Wellness -- Screen 1 -- Select enhanced benefit.  Plan offers CareWise 24-hour Nurse Advice Line through contracting service providers.  The program is not an emergency or urgent care service but provides the following: Unlimited toll-free 24-hour telephone access to registered nurses via dedicated Secure Horizons telephone number Follow-up calls offered for appropriate medical concerns Consumer education brochures sent to callers as appropriate Back-end Audio Library access	2	01000			2	5			10		1				2	1	100.00	1				2	Section B -- 14b Immunizations -- Screen 1 -- Select the Coinsurance Coverage Basis for Medicare Covered Benefits - Hepatitis B.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	01000	1	1	2	1	3	1			2	10.00	1	2	100.00	1				2	300.00	5	3	2	1	Section B -- 14c Routine Phys -- Screen 2 -- Select the Coverage Basis for Maximum Plan Benefit Coverage.  Limit is based upon PacifiCare's contractually negotiated rates; if not available, limit is based on Medicare Allowable Cost (MAC).	2	01000										2	5	5			0	10			1					2	1	100.00	1				2						Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pap Smears.  Enrollees pay nothing for pap smears.  Coinsurance applies to pelvic exam.Section B -- 14d Pap/Pelvic -- Screen 3 -- Select the Coinsurance Coverage Basis for Medicare Covered Pelvic Exams.  Coinsurance is based upon PacifiCare's contractually negotiated rates; if not available, coinsurance is based on Medicare Allowable Cost (MAC).	2	2
H2961	002	1	10	05	01000		1	1	1	1	1	1	1		1	0111110111	1																																				2			5.00	5.00	20.00	5.00	35.00	0.00	0.00	0.00	0.00	5.00			25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances).  Enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  Individual nutrition educational consultations are available as necessary for a $5 copayment.There is a 50% for smoking cessation drugs up to one prescription each month of treatment for one three-month course of treatment per calendar year.	2	00111			2						2				2	3		2				2	No referral is required for network physician.   A doctor office visit and/or professional service copayment may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	No referral is required for network providers.  A doctor office visit and/or professional service copayment may apply as appropriate.	2	
H2961	011	1	10	05	01000				1	1	1	1			1	0110100110	1																																				2						5.00	35.00	0.00	0.00	0.00	0.00				25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances); enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  There is a 50% coinsurance for smoking cessation drugs up to one prescription each month of treatment and one three-month course of treatment per calendar year.	2	00111			2	1			20		1				2	3		2				2	No referral is required for network physician.  Hepatitis vaccinations require a 20% coinsurance and are covered at Medicare's approved amount.Copayments/coinsurance for professional services and/or ancillary services may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1	1	1	1	1	20	20	20	20	1					2	3		2				2					2	No referral is required for network providers.	2	2
H2961	801	1	10	05	01000		1	1	1	1	1	1	1		1	0111110111	1																																				2			5.00	5.00	20.00	5.00	35.00	0.00	0.00	0.00	0.00	5.00			25.00	1		2			2					2	There is no charge for Health and Wellness classes, however, there are class materials fees that vary from $5 to $35 per class (fees can be waived under certain circumstances).  Enrollment in the class entitles the enrollee and a caregiver/coach/helper to attend.  Individual nutrition educational consultations are available as necessary for a $5 copayment for members in Southern Nevada.There is a 50% for smoking cessation drugs up to one prescription each month of treatment for one three-month course of treatment per calendar year.	2	00111			2						2				2	3		2				2	No referral is required for network physician.   A doctor office visit and/or professional service copayment may apply as appropriate.	2	01000	1	1	1			1			2	10.00	1	2		2				2					2	No referral is necessary for network providers.  There is no limit to the number of these visits.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	No referral is required for network providers.  A doctor office visit and/or professional service copayment may apply as appropriate.	2	
H3108	001	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3108	002	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3108	801	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3108	802	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3109	001	1	26	05	01000						2					0000000010	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	Doctor's office copay applies if performed in doctor's office.pneumococcal and flu vacine covered in full.	1	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3109	002	1	26	05	01000						2					0000000010	1																																				2																2		2			2					2		2	01000			2						2				2	3		2				2	Doctor's office copay applies if performed in doctor's office.pneumococcal and flu vacine covered in full.	1	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3323	001	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	002	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	003	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	004	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	801	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2		2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3323	802	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2		2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	1		2				2					2		2	
H3323	803	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	804	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	805	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	806	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	807	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3323	808	1	26	05													2																																																																	01000			2						2	10.00			1	1		2				2	There is no copay for Influenza and pneumococcal vaccines.Office visit copay may apply.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000		2	01		2		1		3	1									2					2	1		2				2					2		2	
H3324	001	1	26	05													2																																																															There is no out-of-network coverage.		01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams.  You are covered up to one (1) exam every year.  If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	15.00		15.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two years.  If you are at high risk of cervical cancer or have had an abnormal Pap test, and are of chilbearing age, you are covered for one Pap test every 12 months.  If services rendered include a physician office visit, a copayment may apply.	2	2
H3324	002	1	26	05													2																																																															There is no out-of-network coverage.		01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams.  You are covered up to one (1) exam every year.  If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	15.00		15.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two years.  If you are at high risk of cervical cancer or have had an abnormal Pap test, and are of chilbearing age, you are covered for one Pap test every 12 months.  If services rendered include a physician office visit, a copayment may apply.	2	2
H3324	003	1	26	05													2																																																															There is no out-of-network coverage.		01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams.  You are covered up to one (1) exam every year.  If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	15.00		15.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two years.  If you are at high risk of cervical cancer or have had an abnormal Pap test, and are of chilbearing age, you are covered for one Pap test every 12 months.  If services rendered include a physician office visit, a copayment may apply.	2	2
H3324	004	1	26	05													2																																																															There is no out-of-network coverage.		01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams.  You are covered up to one (1) exam every year.  If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	10.00		10.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two years.  If you are at high risk of cervical cancer or have had an abnormal Pap test, and are of chilbearing age, you are covered for one Pap test every 12 months.  If services rendered include a physician office visit, a copayment may apply.	2	2
H3324	801	1	26	05													2																																																																	01000			2						2				2	3		2				2	If services rendered include a physician office visit, a copayment may apply.	2	01000	2	1	2	1	3	1			2		2	3		2				2					2	You are covered in full for routine physical exams. You are covered up to one (1) exam every year. If services rendered include other physician services, a copayment may apply.	2	01000	2		10	2		1		3		1									2	0.00	15.00		15.00	1	3		2				2					2	For all women, Pap tests and pelvic exams are covered once every two (2) years. If you are at high risk of cervical cancer or have had an abnornal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.If services rendered include a phyisican office visit, a copayment may apply.	2	2
H3325	001	1	26	05	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-based symptom assessments, self care instructions and member education 24 hours a day.Out-of-network benefits are not available.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is necessary for network providers.Out-of-network benefits are not available.	2	01000	1	1	1			1			2	0.00	1	1		2				2					2	Out-of-network benefits are not available.	2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.Out-of-network benefits are not available.	2	2
H3325	002	1	26	05	01000		1	1			1	1				0010010011	1																																				2																2		2			2					2	The nursing hotline can be accessed via telephone and allows discussion with Registered Nurses (RNs) who provide algorithm-based symptom assessments, self care instructions and member education 24 hours a day.Out-of-network benefits are not available.	2	01000			2						2	0.00			1	3		2				2	Office visit copayment applies when there is an accompanying physician exam.No referral is necessary for network providers.Out-of-network benefits are not available.	2	01000	1	1	1			1			2	0.00	1	1		2				2					2	Out-of-network benefits are not available.	2	01000										2									2	0.00	0.00			1	3		2				2						Office copayment applies when there is an accompanying physician exam.Out-of-network benefits are not available.	2	2
H3326	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	5.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3326	002	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3403	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3615	001	1	26	05	01000		2	2	2			2	2			0111010001	1																																				2																2		2			2					2		2	01000	1	2	1						2				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office visit copayment may apply.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Office Visit copayment may apply.	2	
H3615	801	1	26	05	01000		2	2	2			2	2			0111010001	1																																				2																2		2			2					2		2	01000	1	2	1	2	2	20	20	20	1				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office visit copayment may apply.	2	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1	2	2	2	2	20	20	20	20	1					2	3		2				2					2	Office Visit copayment may apply.	2	2
H3616	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3616	002	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3617	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3617	002	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H3618	001	1	26	05													2																																																																	01000			2						2				2	1		2				2		2	01000	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	1		2				2						Doctor Office visit copay will apply.	2	
H3806	001	1	26	05	01000	2		2								0000001001	1																																				2	15.00	25.00		0.00	0.00											1		2			2	500.00	5		3	1	In network:  $0 for disease management, $15 for chiropractic, naturopathic and acupuncture.  $25 for massage therapy with a 9 visit limit.Out of network: Not covered.This benefit includes chiropractic, naturopathic, acupuncture, and medically indicated massage therapy.In network: There is a combined $500 annual coverage limit for chiropractic, acupuncture, naturopathic and massage therapy.Out of network: Not covered.	2	01000			2						2				2	1		2				2	In and out of network:  $0 immunizations; a $10.00/$20.00 office visit copay will apply if services are received in addition to the immunization.	2	01000	2	1	2	1	3	1			2		2	1		2				2					2	Office visit copay applies.	2	01000	2	2	11	2	2	1	1	2	2	1									2					2	1		2				2					2	Office visit copay applies.	2	
H3851	005	1	18	06	01000			1				1				0010000001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1							2																				01000										2									2					2	3		2				2						If an office visit is billed a copayment will apply	2	
H3851	006	1	18	06	01000			1				1				0010000001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed a copayment will apply	2	
H3851	007	1	18	06	01000			1				1				0010000001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1							2																				01000										2									2					2	3		2				2						If an office visit is billed a copayment will apply	2	
H3851	008	1	18	06	01000			1				1				0010000001	1																																				2																2		2			2					2		1	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	1	00100	1	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000										2									2					2	3		2				2						If an office visit is billed a copayment will apply	2	
H3851	011	2	18	06	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	If an office visit is billed, a copayment will apply.	2							2																				01000										2									2					2	3		2				2						If an office visit is billed, a copayment will apply.	2	
H3909	001	1	23	05	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	25.00	0.00	25.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3909	003	1	23	05	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, cost-sharing may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	10.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	20.00	0.00	20.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a cost-sharing may apply.	2	2
H3909	004	1	23	05	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	15.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	25.00	0.00	25.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3909	801	1	23	05	10000			2	2	2		2	2	2	2	1111100101	1																																				2																2		2			2					2	Weight Management: Reimbursement capped at $200 per 365-day period for plan approved weight management programs. Some restrictions apply.Fitness Reimbursement: Up to $150 reimbursement upon completion of 120 visits within a 365-day period. Some restrictions apply.Smoking Cessation: Up to a $200 maximum reimbursement upon completion of a Smoking Cessation program. Some restrictions apply.Disease Management: Asthma, Cardiac, Congestive Heart Failure, Diabetes Management and Chronic Obstructive Pulmonary Disorder.	2	01000			2						2				2	3		2				2	#14b, Immunizations, Base 2, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, copay may apply.Not covered for travel.	2	01000	2	1	2	1	3	1			2	20.00	1	2		2				2					2		2	01000	2	2	11	2	2	1	1	3	3	1									2	0.00	35.00	0.00	35.00	1	3		2				2					2	#14d, Pap/Pelvic, Base 4, Indicate whether a separate office visit cost share applies for services: If there is a separate and distinct office visit evaluation and service, a copay may apply.	2	2
H3911	801	1	21	05	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office vist may apply.	2	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2	A $20 copayment will apply if performed by a specialist.	2	00111		1	01		2		1		3	1									2					2	3		2				2					2	An office visit copayment may apply.	2	
H3913	001	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	002	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	003	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	004	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	005	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	006	1	26	05	01000		2	2	1							0100010001	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	Out of Network services are not covered.	2	01000	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	Out of Network services are covered at 80%.	2	
H3913	801	1	26	05	01000				1							0100000000	1																																				2																2		2			2					2	The Healthy Lifestyle Product has a specialty network and combines spas as well as fitness centers.  UPMC for Life members would be able to access these centers free of charge.  We will be facilitating specific senior programs, such as Yoga for Seniors, and offering other services beyond no-cost fitness centers and spa access, such as Tai Chi, Qi Gong, Personal Trainers, Pilates classes, and educational programs.	2	01000			2						2				2	3		2				2	Out of Network services are covered at 80% after deductible.	2							2																				01000										2									2					2	2		2				2						.	2	
H3914	001	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3914	002	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3914	801	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3914	802	1	26	05	01000		2	2	2		2	2	2		2	0111110011	1																																				2																2		2			2					2	Out-of-network not covered.Health Education/Wellness programs do not involve classroom instruction.	2	01000	1	2	1						2				2	2		2				2	Covers indicated immunizations based on CDC recommendations except for those for travel or employment.  In addition to Influenza, Hepatitis B and Pneumococcal, could include Tetanus-Diptheria, Hepatitis A, Lyme or Meningitis for high risk or Rubella (women of child-bearing age).No referral necessary for network providers for other immunizations.MMA Eff. 03/01/04:Changed Hepatitis B Copay to $0.	2	01000	2	1	2	1	3	1			2		2	2		2				2					2	MMA Eff. 03/01/04:Changed Routine Physical Copay to $0.	2	00110	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	MMA Eff. 03/01/04:Changed Pap/Pelvic Copays to $0.	2	
H3915	001	1	26	05	01000		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B  #14a Health Ed/Wellness  Base 1  Question:  Do you offer any Additional Benefits?Select enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B  #14b Immunizations  Question:  Indicate whether a separate office visit cost share applies for services.  Physician office visit copayment may apply, except in the case of flu or pneumonia vaccines, where copays are assessed only if another service is rendered in the same visit.  ($10 primary physician copayment or $15 specialist copayment may apply, depending on which provider performs this service.)Sedtion B #14b Immunizations   Question:  Do you offer any Additional Benefits?   100% covergae for Hepatitis B Vaccine.Section B #14b Immunizations  General:20% coinsurance applies to out-of-network coverage.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Section B #14c Routine Phys  Question:  Indicate whether a separate office visit cost share applies for services.   Physician office visit copayment ($10 primary physician copayment or $15 specialist copayment) may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B #14d Pap/Pelvic  Question:  Indicate whether a separate office visit cost share applies for services.   Physician office visit copayment ($10 primary physician or $15 specialist copayment) may apply, depending  on which provider performs this service.	2	
H3915	801	1	26	05	01000		1	1	1			1	1	1	1	1111110001	1																																				2																2		2			2					2	Section B  #14a Health Ed/Wellness  Base 1  Question:  Do you offer any Additional Benefits?Select enhanced benefits include weight and stress management.	2	01000	1	1	1						2				2	3		2				2	Section B  #14b Immunizations  Question:  Indicate whether a separate office visit cost share applies for services.  Physician office visit copayment may apply, except in the case of flu or pneumonia vaccines, where copays are assessed only if another service is rendered in the same visit.  ($10 primary physician copayment or $15 specialist copayment may apply, depending on which provider performs this service.)Sedtion B #14b Immunizations   Question:  Do you offer any Additional Benefits?   100% covergae for Hepatitis B Vaccine.Section B #14b Immunizations  General:20% coinsurance applies to out-of-network coverage.	2	01000	1	1	2	1	3	1			2		2	1		2				2					2	Section B #14c Routine Phys  Question:  Indicate whether a separate office visit cost share applies for services.   Physician office visit copayment ($10 primary physician copayment or $15 specialist copayment) may apply, depending on which provider performs this service.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Section B #14d Pap/Pelvic  Question:  Indicate whether a separate office visit cost share applies for services.   Physician office visit copayment ($10 primary physician or $15 specialist copayment) may apply, depending  on which provider performs this service.	2	
H4103	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H4403	001	1	26	05	01000		1	1			1	1	1			0011010011	1																																				2																2		2			2					2	Participants in the Diabetes Health Improvement Program (DHIP) must meet medical criteria.  Physician office visit copayment may apply.	2	10000	1	1	1						2				2	3		2				2	Copay applies only if immunization administered in conjunction with office visit.  Cariten offers additional immunizations for worldwide travel.	2	01000	1	1	2	1	3	1			2		2	3		2				2					2	Copay for Physician Office Visit may apply	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	Copay for Physician Office Visit may apply	2	
H4404	001	1	26	05	01000			1				1				0010000001	1																																				2																2		2			2					2		2	00100			2						2				2	3		2				2	Office visit copayment can apply -Hepatitis B-$25 OON	1	00100	1	1	2	1	3	1			2	10.00	1	2		2				2					2	$40.00 OON copaymentone exam per year	2	10100										2									2	0.00	25.00			1	3		2				2						OB-GYN or PCP can provide the annual well visit exams.$25.00 copayment OON$0.00 in-networkone exam per year	2	2
H4564	001	1	18	06	00111				2		2	2			2	0110100010	1																																				2						0.00	0.00			0.00	0.00				0.00	1		2			2					2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	00111			2						2	0.00			1	3		2				2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.If a health professional is seen, doctors office visit copayment may apply.	1	00111	2	1	1			1			2	0.00	1	2		2				2					2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	00111										2									2	0.00	0.00			1	3		2				2						Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	2
H4564	002	1	18	06	00111				2		2	2			2	0110100010	1																																				2						0.00	0.00			0.00	0.00				0.00	1		2			2					2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	00111			2						2	0.00			1	3		2				2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.If a health professional is seen, doctors office visit copayment may apply.	1	00111	2	1	1			1			2	0.00	1	2		2				2					2	Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	00111										2									2	0.00	0.00			1	3		2				2						Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1	2
H4564	003	1	18	06	00111						2	2				0010000010	1																																				2										0.00	0.00					1		2			2					2		2	00111			2						2	0.00			1	3		2				2	If member sees a Health Care Professional, then an office visit copayment may be applied.Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.	1							2																		This is not covered.		00111										2									2	0.00	0.00			1	3		2				2						Except for emergency services or urgently needed care, all services covered under this agreement should be provided by Medical Group, Health Professionals and Health Plan Hospitals unless a referral to a nonaffiliated provider is authorized by subscriber's personal physician and Medical Director.  Services rendered by Referral physicians are covered to the extent such services are covered under this agreement.  Some non-covered services may be covered under regular fee-for-service Medicare.  Each referral must be approved separately.  For example, an authorization for treatment by a particular Referral Physician does not also authorize hospitalization in a hospital which is not a Health Plan Hospital.  Must use plan providers.If a health professional is seen, then office visit copayment may apply.	2	2
H5102	003	1	18	06	00001							2			1	0010100000	1																																				2																2		2			2					2		1	01000			2						2				2	2		2				2		2	01000	2	1	1			1			2		2	2		2				2					2		2	01000	1	1	11	1	1					1									2					2	2		2				2					2		2	
H5104	801	1	21	05	01000		1	1	1			1	1			0111010001	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	Enhanced benefits: Tetnus, polio, measels, mumps and rubella.  An office vist may apply.	2	00110	1	1	2	1	3	1			2	10.00	1	2		2				2					2	A $20 copayment will apply if performed by a specialist.	2	00111		1	01		2		1		3	1									2					2	3		2				2					2	An office visit copayment may apply.	2	
H5105	801	1	21	05	00001		2	2				2	2		2	0011110001	1																																				2																2		2			2					2	Prior authorization applies to Nutritional Training, CHF and Disease Management.	2	01000			2						2				2	3		2				2	Office visit copay applies when being treated by a physician for services that require a copay in addition to the immunization.	2	01000	2	1	1			1			2	15.00	1	2		2				2					2		2	01000	2	2	11	1	1					1									2					2	1		2				2					2	Office visit copayment applies when being treated by aphysician for services that require copayment.only one copayment per date of service.	2	
H5254	001	1	18	06	01000			2	2		2	2	2	2	2	1111100011	1																																				2																2		2			2					2	Other benefit is HUGS - a weight management program.Referral and registration is required for for all classes and management programs.	2	00111			2						2				2	2		2				2		1	01000	2	1	2	1	3	1			2		2	2		2				2					2	Member is covered for one routine physical exam annually.	2	00111	2	2	11	2	2	1	1	3	3	1									2					2	2		2				2					2	No referral necessary for network providers.	2	
H5256	001	1	18	06													2																																																																	01000			2						2				2	2		2				2		2	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000		1	01		2		1		3	1									2					2	2		2				2					2		2	
H5400	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS: Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact us for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H5400	002	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESS BENEFITS: Enrollees will also receive reminder notices regarding certain services (Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact us for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H5401	001	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H5401	002	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H5401	003	1	26	05	01000		1	1			1	1		1		1010010011	1																																				2																2		2			2					2	Members must meet clinical protocol to participate in disease management programs-contact plan for details.  Prior authorization is not applicable to member newsletter, nurseline or health education and wellness programs.NOTE ON 'OTHER' HEALTH ED/WELLNESSBENEFITS: Enrollees will also receive reminder notices regarding certain services(Mammography, Flu, Cervical Cancer Screening, Diabetic Eye Exam) when appropriate. Contact UnitedHealthcare for details.SERVICES IN THIS CATEGORY ARE NOT COVERED OUT-OF-NETWORK.	2	01000			2						2				2	3		2				2	PREFERRED BENEFITS:  No copayment for Influenza and Pneumococcal vaccinations. For Hepatitis B vaccinations, members may be charged a copayment/ coinsurance depending on the services received and on the place of service. For physician services the copayment will be as described in section 7 of the PBP. For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	2	1	3	1			2	10.00	1	2		2				2					2	Members will be assessed a copayment for the office visit.  There is no separate copayment for the routine physical exam when an office visit copayment is assessed for the same date of service.  Members may be assessed outpatient cost sharing as described in section 9 of the PBP if they obtain a physical exam at an outpatient or rehabilitation facility.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	01000	1	1	11	2	2	1	1	3	3	1									2					2	3		2				2					2	PREFERRED BENEFITS:  Members may be charged a copayment/coinsurance depending on the services received and on the place of service.  For physician services the copayment will be as described in section 7 of the PBP.  For outpatient services the copayment will be as described in section 9 of the PBP.NONPREFERRED BENEFITS:  20% coinsurance on covered services obtained from a non-contracted provider.	2	
H6360	001	1	18	06	01000		2	2	2		2	2	2	2	2	1111110011	1																																				2																2		2			2					2	The Other classes include a post-heart attack class, a Chronic Obstructive Pulmonary Disease class and a Diabetes Challenge class.  Class-specific fees may apply.	2	00111	1	2	1						2				2	3		2				2	You pay nothing per Hepatitis B vaccine.  You pay nothing per influenza and pneumococcal vaccines when they are the only service rendered during your office visit; otherwise, an office visit copay may apply.Vaccines and immunizations approved for use by the Federal Food and Drug Administration and which are medically indicated and consistent with accepted medical practice are covered, including immunizations related to travel.	1	00111	2	1	1			1			2	15.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Office visit copay applies.	2	
H6360	002	1	18	06	01000		2	2	2		2	2	2	2	2	1111110011	1																																				2																2		2			2					2	The Other classes include a post-heart attack class, a Chronic Obstructive Pulmonary Disease class and a Diabetes Challenge class.  Class-specific fees may apply	2	00111	1	2	1						2				2	3		2				2	You pay nothing per Hepatitis B vaccine.  You pay nothing per influenza and pneumococcal vaccines when they are the only service rendered during your office visit; otherwise, an office visit copay may applyVaccines and immunizations approved for use by the Federal Food and Drug Administration and which are medically indicated and consistent with accepted medical practice are covered, including immunizations related to travel.	1	00111	2	1	1			1			2	25.00	1	2		2				2					2		2	00111										2									2					2	1		2				2						Office visit copay applies	2	
H9101	007	1	10	05	00001			1	1			1		1		1110000001	1																																				2																2		2			2					2	Please contact Elderplan for more details.	1	00101			2						2				2	3		2				2	notes.	1	01000	1	1	2	1	3	1			2		2	3		2				2					2	Notes	2	00111										2									2					2	3		2				2						Notes.	2	
H9103	001	1	10	05	10000			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, several classes in disease management, class- and phone-based smoking cessation, a pain management program, online health assessment, information in medical and drug encyclopedias, and health education resource centers that include both books and videos on numerous health issues. Cost for health education classes and programs vary. Some classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	Immunizations are provided at no charge when medically indicated & consistent with accepted medical practice. Some of the immunizations provided without charge include: hepatits B, travel immunizations, flu & pneumococcal vaccines, cholera, tetanus toxoid, menigococcal vaccine, polio, snakebite, typhoid & yellow fever immunizations.Immunizations that are required for travel are covered. If a member sees their provider as part of getting the referral for an immunization, the office visit charge would apply. Members may self-refer for flu vaccine.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.Member should consult with their provider for how often they should be seen for preventive care.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9103	005	1	10	05	10000			2	2	2	2	2	2	2	2	1111100111	1																																				2				8.00	100.00	0.00	140.00	0.00	0.00	0.00	0.00	8.00	85.00	90.00	100.00	1		2			2					2	KP offers several weight management programs, several classes in disease management, class- and phone-based smoking cessation, a pain management program, online health assessment, information in medical and drug encyclopedias, and health education resource centers that include both books and videos on numerous health issues. Cost for health education classes and programs vary. Some classes require physician or provider referral.	1	00110	1	2	1						2				2	3		2				2	Immunizations are provided at no charge when medically indicated & consistent with accepted medical practice. Some of the immunizations provided without charge include: hepatits B, travel immunizations, flu & pneumococcal vaccines, cholera, tetanus toxoid, menigococcal vaccine, polio, snakebite, typhoid & yellow fever immunizations.Immunizations that are required for travel are covered. If a member sees their provider as part of getting the referral for an immunization, the office visit charge would apply. Members may self-refer for flu vaccine.	1	01000	2	1	2	1	2	1			2	15.00	1	2		2				2					2	Member pays office visit copayment for services provided as part of a preventive care visit, e.g. lab & diagnostic x-rays are $0 copay, physical exam, hearing and vision exams are at the office visit copayment of $15.Member should consult with their provider for how often they should be seen for preventive care.	2	01000										2									2	0.00	15.00			1	2		2				2							2	2
H9104	006	1	10	05	01000				1			1				0110000000	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	SCAN provides additional coverage for immunizations as recommended by the U.S. Preventive Services Task Force.Physician office visit copayment applies if injections are provided by a physician.  If a nurse or other non-physician professional administers injection, no office visit copayment applies.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	1		2				2						Enrollees may self-refer to an OB/GYN within the SCAN network.	2	
H9104	007	1	10	05	01000				1			1				0110000000	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	SCAN provides additional coverage for immunizations as recommended by the U.S. Preventive Services Task Force.Physician office visit copayment applies if injections are provided by a physician.  If a nurse or other non-physician professional administers injection, no office visit copayment applies.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	1		2				2						Enrollees may self-refer to an OB/GYN within the SCAN network.	2	
H9104	008	1	10	05	01000				1			1				0110000000	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	SCAN provides additional coverage for immunizations as recommended by the U.S. Preventive Services Task Force.Physician office visit copayment applies if injections are provided by a physician.  If a nurse or other non-physician professional administers injection, no office visit copayment applies.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	1		2				2						Enrollees may self-refer to an OB/GYN within the SCAN network.	2	
H9104	009	1	10	05	01000				1			1				0110000000	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	SCAN provides additional coverage for immunizations as recommended by the U.S. Preventive Services Task Force.Physician office visit copayment applies if injections are provided by a physician.  If a nurse or other non-physician professional administers injection, no office visit copayment applies.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	1		2				2						Enrollees may self-refer to an OB/GYN within the SCAN network.	2	
H9104	801	1	10	05	01000				1			1				0110000000	1																																				2																2		2			2					2		2	00111	1	1	1						2				2	3		2				2	SCAN provides additional coverage for immunizations as recommended by the U.S. Preventive Services Task Force.Physician office visit copayment applies if injections are provided by a physician.  If a nurse or other non-physician professional administers injection, no office visit copayment applies.	1	01000	1	1	2	1	3	1			2		2	2		2				2					2		2	01000										2									2					2	1		2				2						Enrollees may self-refer to an OB/GYN within the SCAN network for routine preventive care.Office visit applies.	2	
