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In-Network Plan Benefits

In-Network benefits are subject to a copay when you visit a physician for service. The copay amounts are as follows:

  • $15 for a Primary Care Physician (PCP) or an in-store health clinic;
  • $30 when you visit a Specialist;
  • $15 for Psychological Counseling;
  • $25 for Hospital Emergency Room visits, but this copay will be waived if the individual is admitted; and
  • $10 copay for Short-Term Rehabilitation (STR) visits (see the explanation below).

Short-Term Rehabilitation (STR) — The Premier Plan contains a special lower copay which applies when Members seek STR therapy. This lower copay applies to visits to providers who treat Members with this therapy because the therapy frequently involves several visits and the completion of the course of therapy is often necessary in order to achieve the desired result. Physician visits for STR include visits for the following therapies:

  • Occupational Therapy;
  • Physical Therapy;
  • Speech Therapy;
  • Cardiac Rehabilitation Therapy;
  • Pulmonary Rehabilitation Therapy; and
  • Cognitive Therapy.

There is a 60-visit annual limit that applies to all of the visits for the services listed above during the calendar year. For example, if you have 20 visits to an Occupational Therapist and 40 visits to a Physical Therapist in the same year, you will have reached the 60-visit limit.

The STR copay also applies for visits to a Network chiropractor. There is a separate 60-visit annual limit for chiropractor visits during the calendar year.

In addition, the STR copay applies to diagnostic radiology which includes but is not limited to:

  • Diagnostic Mammogram;
  • Magnetic Resonance Imaging (MRI);
  • PET Scan;
  • CAT Scan; and
  • X-Ray and Sonogram.


Note that if a condition has been diagnosed and the purpose of the radiology is for treatment, the regular specialist copay of $30 will apply instead of the STR copay of $10.

There is no copay when you are hospitalized at an In-Network hospital or have a test or procedure in the outpatient department of an In-Network hospital. Visits to the emergency room of an In-Network or Out-of-Network hospital for routine (non-emergency) medical treatment are not covered.