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Persons: 1 |
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Outpatient Services |
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| Individual ? | |||||||
| Family ? | |||||||
Preventive Services |
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| General Practitioner / PCP ? | |||||||
| Specialist ? | |||||||
| Subspecialist ? | |||||||
| Nutritionist ? | |||||||
| Chiropractor ? | |||||||
| Outpatient Facility ? | |||||||
| Prescribed Medical Equipment (DME) ? | |||||||
Laboratory, X-Ray, Specialized and Imaging |
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| Preventive Services ? | |||||||
Emergency/Urgent Care Services |
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| Laboratories ? | |||||||
| X-Rays ? | |||||||
| Sonogramas, CT, MRI ? | |||||||
Hospitalization/Inpatient |
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| Urgent Care Services ? | |||||||
| Emergency Services: Accident / Illness ? | |||||||
Surgical Assistant |
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| Hospitalization/Inpatient Partial (Including Mental Health) ? | |||||||
| Hospitalization/Inpatient Complete (Including Mental Health) ? | |||||||
| Skilled Nursing Facility ? | |||||||
Emergency Services in the United States or Services in Cases that Require Equipment, Treatment and Facilities That Are Not Available In Puerto Rico. |
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| Surgical Assistant ? | |||||||
Vision |
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| Emergency Services in the United States or Services in Cases that Require Equipment, Treatment and Facilities That Are Not Available In Puerto Rico. ? | |||||||
| Urgent Care Services in the United States - Sanitas ? | |||||||
Dental Coverage |
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| Refraction Test (Vision for Children and Adults) ? | |||||||
| Pediatric Vision (Visual Correction Lenses or Frames for Visual Correction Lenses) ? | |||||||
| Glasses or Contact Lenses for Adults ? | |||||||
Pharmacy Coverage |
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| Preventive and Diagnostic ? | |||||||
Other Services |
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| Drug List ? | |||||||
| Annual Deductible ? | |||||||
| First Level of Coverage ? | |||||||
| Generics ? | |||||||
| Preferred Brand ? | |||||||
| Non-preferred Brand ? | |||||||
| Preferred Specialty ? | |||||||
| Non-preferred Specialty ? | |||||||
| Over The Counter Drugs (OTC) ? | |||||||
| Coinsurance After First Level of Coverage ? | |||||||