Autograph Total/5000 Plus Rx/HSA Health Insurance Plan Details

	Autograph Total/5000 Plus Rx/HSA

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
0% Coinsurance after deductible
Office Visit for Specialist
0% Coinsurance after deductible
Coinsurance
0% after deductible
Separate Prescription Drugs Deductible
Medical Plan Deductible Applies
Prescription Drugs
0% 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. 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
0% Coinsurance/No Deductible
to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
Periodic OB-GYN Exam
Exam/Pap Smear: 0% Coinsurance/ No Deductible
to $300/Calendar Year Preventive Care Maximum
90 Day Waiting Period
Mammogram: 0% Coinsurance/ No Deductible
Does not apply to $300/Calendar Year Preventive Care Maximum
No Waiting Period
Well Baby Care
0% Coinsurance/ No Deductible to $300/Calendar Year Preventive Care Maximum
90 Day Waiting Period

Chiropractic Coverage
0% 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