Monogram Total/7500 Plus Rx Health Insurance Plan Details

	Monogram Total/7500 Plus Rx

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
$1,000 Individual
Applies to Levels 2, 3, 4
Prescription Drugs
Rx Deductible for Levels 2, 3, 4
Level 1: $15 copay
Level 2: $40 copay
Level 3: $65 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
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, No 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
Outpatient Care (Does not include outpatient alcohol and chemical dependence): 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