Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• No Charge after deductible
• Office Visit for Specialist
• No Charge after deductible
• Coinsurance
• No Charge after deductible
• Separate Prescription Drugs Deductible
• Medical Plan Deductible Applies
• Prescription Drugs
• Generic: No Charge after deductible
• Brand: No Charge after deductible
• Non-Formulary: No Charge after deductible
• 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
• No Charge. $300 Annual Maximum on All Preventive Benefits
• Periodic OB-GYN Exam
• No Charge. $300 Annual Maximum on All Preventive Benefits
• Well Baby Care
• $30 Copay to age 18

Prescription Drug Coverage

• Generic Prescription Drugs
• No Charge after deductible
• Brand Prescription Drugs
• No Charge after deductible
• Non-Formulary Prescription Drugs Coverage
• No Charge after deductible
• Mail Order for Prescription Drugs
• Generic: No Charge after deductible
• Brand: No Charge after deductible
• Non-Formulary: No Charge after deductible
• Days Supply: 90
• Separate Prescription Drugs Deductible
• Medical Plan Deductible Applies

Hospital Services Coverage

• Emergency Room
• No Charge after deductible
• Outpatient Lab/X-Ray
• No Charge after deductible
• Outpatient Surgery
• No Charge after deductible
• Hospitalization
• No Charge after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not Covered
• Labor & Delivery Hospital Stay
• No charge after deductible, complications only

Additional Coverage

• Chiropractic Coverage
• No charge after deductible. 20 visits max
• Mental Health Coverage
• Not Covered

Additional Information

• A.M. Best Rating
• A- as of 11/19/2008
• 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