Services Independent of an Office Visit

The information below applies to the HPH/HMO Commercial Copay Table.

General Provisions Applicable to Coverage Codes Listed

Services include radiotherapy, diagnostic and therapeutic endoscopic procedures, diagnostic and therapeutic injections (including catheters), injections into joints, muscles and tendons, orthopedic castings, acne treatment, destruction of localized surface lesions by chemotherapy (excluding silver nitrate), cryotherapy and electrosurgery. Copayments expressed as percentages represent the member's portion of HMSA's eligible charge.

Note: For services provided on the same day in conjunction with other services for which a copayment is made, there is no charge to the member. Also, there are no member copayments for tests received in the practitioner?s office.

Footnotes

This plan pays for 100 percent of eligible charges when services are provided in conjunction with a covered office visit. Services such as diagnostic and therapeutic endoscopic procedures; diagnostic and therapeutic injections; injections into joints; orthopedic castings; destruction of localized surface lesions by chemotherapy (excluding silver nitrate); cryotherapy; or electrotherapy, count against the maximum of three outpatient surgeries per calendar year.

1. When services are received from a non-network participating provider or a non-network, nonparticipating provider, the copayments will be higher. Allergy testing is limited to one test series per calendar year, including allergy treatment materials.
2. This plan covers 100 percent of eligible charges for laboratory services, diagnostic tests, and X-ray exams and mammography.
3. This plan covers 100 percent of eligible charges for lab tests, diagnostic tests and X-rays and screening mammograms. The member copayments for this plan are:
   • 20 percent of eligible charges for diagnostic endoscopic procedures; diagnostic injections (including catheters); injections into joints, muscles, and tendons; orthopedic castings; acne treatment; destruction of localized surface lesions by chemotherapy (excluding silver nitrate); cryotherapy; and electrosurgery
   • 50 percent of eligible charge for radiotherapy
   • $12 copay for allergy testing and treatment

   The above coverage is subject to the following limitations: Pap smear (one per year); PSA (one per year for men 50 years and older); TB tine test (one per year).

4. This plan covers 100 percent of eligible charges for laboratory tests, diagnostic tests and X-rays. The member copayments for this plan are:
   • 30 percent of eligible charges for diagnostic endoscopic procedures; diagnostic injections (including catheters); injections into joints, muscles, and tendons; orthopedic castings; acne treatment; destruction of localized surface lesions by chemotherapy (excluding silver nitrate); cryotherapy; or electrosurgery
   • 50 percent of eligible charge for radiotherapy
   • $25 copayment for allergy testing and treatment
   • 20 percent of eligible charge for screening mammography
5. This plan covers 100 percent of eligible charges for laboratory tests, diagnostic tests, X-rays and screening mammograms. The member copayments for this plan are:
   • 20 percent of eligible charges for diagnostic endoscopic procedures; diagnostic injections (including catheters); injections into joints, muscles, and tendons; orthopedic castings; acne treatment; destruction of localized surface lesions by chemotherapy (excluding silver nitrate); cryotherapy; or electrosurgery
   • 50 percent of eligible charge for radiotherapy
   • $15 copayment for allergy testing and treatment
6. The plan requires a copayment if services are provided during a separate visit as an independent visit. This plan has a 12-month waiting period for any pre-existing illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a pre-existing illness or condition.
7. This plan has a 12-month waiting period for any pre-existing illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a pre-existing illness or condition. The plan has a 12-month waiting period for maternity care, pregnancy, childbirth and related conditions.
8. Outpatient radiology and X-rays from a network provider will be covered at 90 percent of Eligible Charge.
9. This plan covers 100 percent of eligible charges for lab tests, diagnostic tests and X-rays and screening mammograms. The member copayments for this plan are:
   • 20 percent of eligible charges for diagnostic endoscopic procedures; diagnostic injections (including catheters); injections into joints, muscles, and tendons; orthopedic castings; acne treatment; destruction of localized surface lesions by chemotherapy (excluding silver nitrate); cryotherapy; and electrosurgery
   • 50 percent of eligible charge for radiotherapy
   • $14 copay for allergy testing and treatment

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