All benefits are subject to applicable deductible or co-payment.
This chart should be used in conjunction with the Evidence of Coverage and the Sales and Enrollment Brochure for a complete complete description of benefits, exclusions and limitations, and participation requirements. This chart is not a contract nor is it a solicitation of an application. It describes benefits in general terms. An application for coverage is only by formal quote. All services must be authorized by your PMG or IPA to be considered eligible.