Pinnacle 2026

Generic And Brand Name Prescriptions

$10,000 Maximum Per Calendar Year

Home Delivery Service is Avaliable

1. Preventative health exam for children and related services as outlined below and performed by the physician during the preventative health exam or referred by the physician as appropriate, including: Well Child visits for children through age 6 and specified immunizations​.

1. Annual well woman exam:
   • Routine well woman preventative exam office visit, by Network Physician, is subject to copayment
   • Screening mammography at age 40 and older, with one baseline mammogram between the ages of 35 and 39; subject to CYD/ coinsurance.
   • Annual routine Pap Smear if rendered by a In-Network physician’s office will be subject to copay. Services rendered in an Out-of- Network physician’s office will be subject to CYD and Out-of-Network coinsurance.

1. Colorectal cancer screening at age forty-five (45) and older as follows: High-Sensitivity Guaiac Fecal Occult Blood Test (HSgFOBT), or Fecal Immunochemical Test (FIT) every year; tool DNA-FIT every one to three years; Computed Tomography Colonography every five years; Flexible Sigmoidoscopy every five years; Flexible Sigmoidoscopy every 10 years + annual FIT; and Colonoscopy screening every 10 years.

1. Benefits will be provided, subject to deductible and coinsurance, for one routine Prostate-Specific Antigen (PSA) per calendar year, when services are rendered by an independent laboratory or other outpatient setting.

Maternity benefits will be provided after an individual’s coverage on a family contract has been in effect for nine consecutive months. Individual coverage has NO maternity benefits except for complications of pregnancy.

Benefits will not be provided for any pre-existing condition until an individual has completed a waiting period of at least 12 months. A pre-existing condition is defined in the contract as “An illness, injury, pregnancy or any other medical condition which existed at any time preceding the effective date of coverage under this contract for which: Medical advice or treatment was recommended by or received from a provider of health care services, or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.”

*Copayments will be applied to each office visit for the covered services performed in the office and provided and billed by a physician who is an In-Network provider. The remaining charges for covered services rendered during the office visit will be paid at 100% of the maximum allowable charge. If a physician who is an Out-of Network provider is utilized for covered services, benefits will be determined on the basis of the Out-of- Network coinsurance percentage after deductible is met. Copayments will not be applied toward deductibles or out-of-pocket maximums.

Copayments do not apply to the following services: advanced radiological imaging, all maternity services, all therapeutic services, allergy testing and injections, biopsy interpretations, bone density testing, cardiac diagnostic testing, chemotherapy services, chiropractic services, complex diagnostic services, dental services, diagnostic testing sent out, DME and DME supplies, growth hormone injections, IV therapy, Lupron injections, mammography, nerve conduction studies, neuropsychological or neurological tests, nuclear cardiology, nuclear medicine, orthotics, prosthetics, provider administered specialty pharmacy products, sleep studies, surgery performed in a physician’s office and related surgical supplies, Synagis injections, and ultrasounds. These services will be covered under normal contract benefits, subject to the terms and conditions of this contract. Deductible and coinsurance will apply.