outpatient hospital $0 copay 
Outpatient surgery at 
ambulatory surgical center $0 copay 
DOCTOR OFFICE VISITS 
Primary care provider (PCP) $0 copay 
Specialists $0 copay 
PREVENTIVE CARE 
N/A Our plan covers many preventive services at no cost when you see  
an in-network provider including: 
•Abdominal aortic aneurysm Screening 
•Alcohol misuse counseling 
•Bone mass measurement 
•Breast cancer screening (mammogram) 
•Cardiovascular disease (behavioral therapy) 
•Cardiovascular screenings