Autograph Total/2500 Plus Rx/HSA Health Insurance Plan Details

	Autograph Total/2500 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% Coinsurance after deductible
Separate Prescription Drugs Deductible
Medical Plan Deductible Applies
Prescription Drugs
0% Coinsurance 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 (birth to age 18): 20% Coinsurance/No Deductible; to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period;
Mammogram/Pap Smear (age 18 and older) : 20% Coinsurance/ No Deductible; No Preventive Care Maximum/No Waiting Period
Well Baby Care
Child Exam & Immunizations (age 6-18): 0% Coinsurance/No Deductible; to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
Immunizations (birth to age 6): 0% Coinsurance/No Deductible; No Preventive Care Maximum; No Waiting Period

Chiropractic Coverage
0% Coinsurance after deductible
20 Visits/Calendar Year
(Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Mental Health Coverage
25% 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)
30 day waiting period