Office/Outpatient Care |
C1 |
C2 |
C3 |
 C4* |
|---|---|---|---|---|
| Doctor’s Office Visits | ||||
| Primary and OB/GYN Care | $10 | $20 | $30 | $30 |
| Specialist | $20 | $30 | $40 | $50 |
| Physical/Occupational Therapy | ||||
| (30 visits per cal. year**) | $20 | $30 | $40 | $50 |
| Spinal Manipulations and Speech Therapy | ||||
| (20 visits each per cal. year**) | $20 | $30 | $40 | $50 |
| Cardiac and Pulmonary Rehabilitation | ||||
| (36 sessions each per cal year**) | $20 | $30 | $40 | $50 |
| X-Ray/Radiology/Diagnostics | ||||
| Routine Radiology | $20 | $30 | $40 | $50 |
| MRI/MRA, CT Scans, PET Scans*** | $40 | $60 | $80 | $100 |
| Injectable Medications | ||||
| Standard Injectables | $0 | $0 | $0 | $0 |
| Biotech/Specialty Injectables*** | $50 | $75 | $100 | $125 |
| Lab/Pathology | ||||
| Copayment | $0 | $0 | $0 | $0 |
Coinsurance is based upon plan allowance and reflects amount paid by the plan.
* C4 can only be paired with F3, F4, or F5.
** For AmeriHealth POS and POS Direct, combined in/out-of-network maximum.
*** Preauthorization required for certain services.