Portrait Share 80/2500 Plus Rx & Unlimited Doctor Visit Copay Health Insurance Plan Details

	Portrait Share 80/2500 Plus Rx & Unlimited Doctor Visit Copay

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
$35 copay
Office Visit for Specialist
$50 copay
Coinsurance
20% after deductible
Separate Prescription Drugs Deductible
$500 Individual; Applies to Levels 2, 3, 4.
Prescription Drugs
Rx Deductible for Levels 2, 3, 4
Level 1: $15 copay
Level 2: $35 copay
Level 3: $55 copay
Level 4: 25% copay up to $2500 maximum out of pocket.
Levels based on specific drug
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Emergency Care Only. Paid as out-of-network, and member must submit an itemized bill with services rendered and a diagnosis in order to be reimbursed.

Periodic Health Exam
20% Coinsurance/
No Deductible
to $300/Calendar Year Preventive Care Maximum;
90 Day Waiting Period.
Periodic OB-GYN Exam
Exam/Pap Smear: 20% Coinsurance/
No Deductible
to $300/Calendar Year Preventive Care Maximum;
90 Day Waiting Period;
Mammogram: No Charge/No Deductible;
Does not apply to $300/Calendar Year Maximum;
No Waiting Period.
Well Baby Care
Child Health Supervision Services:
Limited to 18 Visits from birth to age 17,
Includes immunizations;
20% Coinsurance/No Deductible;
Does not apply to $300/Calendar Year Preventive Care Maximum;
No Waiting Period.

Emergency Room
$75 Copay
plus 20% Coinsurance after deductible.
(copay waived if admitted)
Outpatient Lab/X-Ray
First $200 per cal year at 0% Coinsurance,
then 20% Coinsurance after deductible
Outpatient Surgery
20% Coinsurance after deductible
Hospitalization
20% Coinsurance after deductible

Chiropractic Coverage
20% Coinsurance after deductible.
20 Visits/Calendar Year.
(Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Mental Health Coverage
50% Coinsurance after deductible;
$2500/Calendar Year Maximum.
Outpatient care not to exceed $500 of the $2500 Calendar Year Maximum.
(Combined Mental Disorders/Alcohol and Chemical Dependence Calendar Year Max)
One year waiting Period.