*A copayment will be applied to each office visit for the covered services performed in the office and provided and billed by a physician who is an in-network provider. The remaining charges for covered services rendered during the office visit will be paid at 100% of the maximum allowable charge. If a physician who is an out-of-network provider is utilized for covered services, benefits will be determined on the basis of the out-of-network coinsurance percentage after deductible is met.
Copayments do not apply to the following services: advanced radiological imaging, allergy testing and injections, biopsy interpretation, bone density testing, cardiac diagnostic testing, chemotherapy services, chiropractic services, dental services except preventative and restorative for all members, diagnostic services sent out, durable medical equipment, growth hormone injections, IV therapy, Lupron injections, mammography, maternity services, nerve conduction studies, neuropsychological or neurological tests, nuclear cardiology, nuclear medicine, orthotics, preventative services as indicated in contract, prosthetics, provider administered specialty pharmacy products, sleep studies, surgery performed in a physician’s office and related surgical supplies, Synagis injections, therapeutic/rehabilitative services, ultrasounds and vision services.
These services are subject to the terms and conditions of the contract and deductibles and coinsurance will apply except where otherwise indicated. Copayments will not be applied toward deductibles or out-of-pocket maximums.