Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• $50
• Office Visit for Specialist
• $75
• Coinsurance
• 30%
• Separate Prescription Drugs Deductible
• $250
• Prescription Drugs
• Generic: $10 Copay
• Brand: $40 after $250 deductible
• Non-Formulary: $75 after $250 deductible
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• No

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• 1st $200 not subject to deductible; PCP $50; Specialist $75
• Periodic OB-GYN Exam
• 1st $200 not subject to deductible; PCP $50; Specialist $75
• Well Baby Care
• 1st $200 not subject to deductible; PCP $50; Specialist $75

Prescription Drug Coverage

• Generic Prescription Drugs
• $10 Copay
• Brand Prescription Drugs
• $40 after $250 deductible
• Non-Formulary Prescription Drugs Coverage
• $75 after $250 deductible
• Mail Order for Prescription Drugs
• Generic: $10 Copay
• Brand: $40 after $250 deductible
• Non-Formulary: $75 after $250 deductible
• Days Supply: 30-90
• Separate Prescription Drugs Deductible
• $250

Hospital Services Coverage

• Emergency Room
• $200 copay (waived if admitted)
• Outpatient Lab/X-Ray
• 30% after deductible
• Outpatient Surgery
• 30% after deductible
• Hospitalization
• 30% after deductible

Maternity Coverage

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

Additional Coverage

• Chiropractic Coverage
• $75 Not subject to deductible Limit 12 visits per Calendar year
• Mental Health Coverage
• Must purchase optional rider: 30% after deductible Limit: OP 25 visits, IP 20 days per Calendar year

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