Office Setting Services

If using network providers PPO Select Choice, a preferred provider health benefit insurance plan, pays

Physician Services

Allergy Injections (billed with the office visit; when billed separately, medical / surgical coinsurance applies plus any applicable deductible)**
Allergy Tests
Consultation
Dental Exam (within the first 48 hours after an accident)
Hearing Exam Office Visit Charge**
Injections (except allergy injections), if billed as injections only
Office Visit
Routine Immunizations (age 8 and over)**
Routine Physical Exam Office Visit**
Vision Exam**
Well-baby Exam**
Well-woman exam** (including pap smear if filed before $300 annual max is exhausted)

100% of allowable amount after copay

Immunizations
(birth through age 7)

100% of allowable amount

Diagnostic Tests
Lab – Office
X-Ray – Office

100% of allowable amount after deductible

Other Benefits
Certain Outpatient Procedures
Office Surgery
Physical / Occupational Therapy**

Coinsurance after deductible