Benchmark plan benefits and copayments.

Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription.

Physicians’ services, including one annual routine physical examination, with a copayment of no more than $15 per visit.

Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.

Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.

Laboratory and X-ray services, including mammography.

Home health services, limited to 60 visits per year.

Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).

Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.

Transportation to obtain medical care, as medically necessary, and, to the extent permitted under federal law, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.

Early childhood developmental services, for children under 6 years of age.

Smoking cessation treatment, for pregnant women only.

Prenatal care coordination, for pregnant women at high risk only.

Early and periodic screening and diagnosis, and all services included in the definition of “medical assistance” under 42 USC 1396d (a) that are found necessary by this screening and diagnosis, for recipients under 21 years of age.