Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• First 6 visits (combined Primary and Specialist). $35 copay, thereafter subject to deductible & 20% coinsurance.
• Office Visit for Specialist
• First 6 visits (combined Primary and Specialist). $50 copay, thereafter subject to deductible & 20% coinsurance.
• Coinsurance
• 20% 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: $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. 

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• 20% Coinsurance/No Deductible
  to $300/Calendar Year Preventive Care Maximum
  90 Day Waiting Period
• Periodic OB-GYN Exam
• Exam: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
  Pap Smear/Mammogram: 20% Coinsurance/No Deductible; No Preventive Care Maximum. No Waiting Period
• Well Baby Care
• Immunizations birth to age 5: 0% Coinsurance/No Deductible; No Preventive Care Maximum. No Waiting Period.
  Other services: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period

Prescription Drug Coverage

• Prescription Drugs Other Coverage
• 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
• Mail Order for Prescription Drugs
• Rx Deductible for Levels 2, 3, 4
  Level 1: $45 copay
  Level 2: $105 copay
  Level 3: $165 copay
  Level 4: 75% copay up to $2500 maximum out of pocket.
  Levels based on specific drug
• Days Supply: 90
• Separate Prescription Drugs Deductible
• $1,000 Individual
  Applies to Levels 2, 3, 4.

Hospital Services Coverage

• Emergency Room
• $75 Copay (waived if admitted) plus 20% Coinsurance after deductible
• 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

Maternity Coverage

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

Additional Coverage

• Chiropractic Coverage
• 20% Coinsurance after deductible.
  20 Visits/Calendar Year
  (Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
• Mental Health Coverage
• Mental Disorder: 20% Coinsurance after Deductible to 90 days/calendar year maximum
  Alcohol and Chemical Dependence Inpatient: 20% Coinsurance after Deductible to 21 days/calendar year maximum. Outpatient: 20% Coinsurance after Deductible to 26 days/calendar year maximum

Additional Information

• A.M. Best Rating
• A- as of 06/05/2009
• 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