Monthly Premiums

• $4 to $12 per child per month
• $36 maximum per family per month

(If you pay for three months in advance, you get the fourth month free.)

Co-payments

CATEGORY

TYPES OF SERVICES

COPAYMENT

Health Facilities

All patient acute & Skilled Nursing (100 days)

No co-payment

All Outpatient Services

$5 co-payment

Professional Services

Inpatient-based

No co-payment

Office or home visit

$5 co-payment

Visits for chemotherapy, dialysis, surgery, anesthesiology, radiation

$5 co-payment

Preventive Services

Visits for immunizations, periodic health exams, well-child visits, STD tests, cytology exams, family planning, vision and hearing tests, prenatal care, health education

No co-payment

Diagnostic x-ray and Laboratory Services

Therapeutic radiology services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests

No co-payment

Prescriptions

Generic or name brand drugs

$5 co-payment

Inpatient drugs and drug administration in a physician's office, as well as FDA-approved contraception drugs and devices

No co-payment

Mental Health

Inpatient limited to 30 days/year

No co-payment

Outpatient visits up to 20 visits per year

$5 co-payment

Drug and Alcohol

Inpatient detoxification

$5 co-payment

Crisis intervention and abuse treatment

$5 co-payment

Other Services

Orthoses, prostheses, medical transportation

No co-payment

Physical, occupational, and speech therapy

$5 co-payment