Copay Select 100 - 1000 Health Insurance Plan Details

	Copay Select 100 - 1000

Details at a Glance

Plan Type
Network
Office Visit for Primary Doctor
History and Exam: $35 Copay
Office Visit for Specialist
History and Exam: $35 Copay
Coinsurance
None
Separate Prescription Drugs Deductible
Tiers 2-4: Combined $200 per person, per calendar year deductible
Prescription Drugs
Tier 1: $15 copay
Tier 2: $35 copay
Tier 3: $65 copay
Tier 4: You pay 25% coinsurance
(Maximum $3,000 per covered person, per calendar year)
(See sample list of drugs)
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Emergency Care Only

Prescription Drugs Other Coverage
Tier 1: $15 copay
Tier 2: $35 copay
Tier 3: $65 copay
Tier 4: You pay 25% coinsurance
(Maximum $3,000 per covered person, per calendar year)
(See sample list of drugs)
Mail Order for Prescription Drugs
Not Available
Separate Prescription Drugs Deductible
Tiers 2-4: Combined $200 per person, per calendar year deductible

Emergency Room
Illness: No Charge after deductible, additional $100 Copay per visit if not admitted; Injury: No Charge after deductible
Outpatient Lab/X-Ray
No Charge after deductible
Outpatient Surgery
No Charge after deductible
Hospitalization
No Charge after deductible

Chiropractic Coverage
No Charge after deductible (limited to $2,000 of covered expenses per calendar year)
Mental Health Coverage
No Charge after deductible ($50 Max. Benefit Per Visit. $3,000 Max. Benefit for lifetime)