Details at a Glance

• Plan Type
• Network
• Office Visit for Primary Doctor
• History and Exam: $35 Copay (Max. 2 visits per year, all doctors)
• Office Visit for Specialist
• History and Exam: $35 Copay (Max. 2 visits per year, all doctors)
• Coinsurance
• 30% after deductible
• Separate Prescription Drugs Deductible
• None
• Prescription Drugs
• Generic: $15 Copay
• Brand: Not Covered
• Non-Formulary: Not Covered
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• Emergency Care Only

Physicians

• Primary Care Physician (PCP) Required
• No
• Specialist Referrals Required
• No

Preventive Care Coverage

• Periodic Health Exam
• $35 Copay, subject to visit limit stated above (3 month waiting period, not subject to deductible)
• Periodic OB-GYN Exam
• Mammogram, Pap Smear, PSA Testing: 30% Coinsurance after deductible
• Well Baby Care
• Not Covered

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay
• Brand Prescription Drugs
• Not Covered
• Non-Formulary Prescription Drugs Coverage
• Not Covered
• Mail Order for Prescription Drugs
• Not Available
• Separate Prescription Drugs Deductible
• None

Hospital Services Coverage

• Emergency Room
• Illness & Injury: 30% Coinsurance after deductible, additional $500 Copay per visit if not admitted
• Outpatient Lab/X-Ray
• 30% Coinsurance after deductible if performed within 14 days of surgery or confinement
• Outpatient Surgery
• 30% Coinsurance after deductible
• Hospitalization
• 30% Coinsurance after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not Covered
• Labor & Delivery Hospital Stay
• Not Covered

Additional Coverage

• Chiropractic Coverage
• Not Covered
• Mental Health Coverage
• Not Covered

Additional Information

• A.M. Best Rating
• A as of 06/15/2009
• Electronic Signature for Application Available
• Yes
• Will insurance company obtain and pay for medical records?
• Yes
• Additional information about this health insurance plan is available in the documents below.
  Plan Brochure
  Exclusions and Limitations

Action

• Get live professional advice about this insurance plan
• Get Live Advice