Details at a Glance

• Plan Type
• Network
• Office Visit for Primary Doctor
• Not Covered
• Office Visit for Specialist
• Not Covered
• Coinsurance
• None
• Separate Prescription Drugs Deductible
• None
• Prescription Drugs
• Generic: Not Covered
• Brand: Not Covered
• Non-Formulary: Not Covered
• Health Savings Account (HSA) Eligible
• Yes ( See HSA Administrators)
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• Emergency Care Only

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• Adult -- Not Covered; Child Ages 0-12 --No Charge; Child Ages 13-18 -- Not Covered
• Periodic OB-GYN Exam
• Mammogram: No Charge up to $97; PSA: No charge up to $65
• Well Baby Care
• Child Immunizations Ages 0-12 -- Vaccine: No Charge; Ages 13-18 -- Vaccine: Not Covered

Prescription Drug Coverage

• Generic Prescription Drugs
• Not Covered
• Brand Prescription Drugs
• Not Covered
• Non-Formulary Prescription Drugs Coverage
• Not Covered
• Mail Order for Prescription Drugs
• Not Available
• Separate Prescription Drugs Deductible
• None

Hospital Services Coverage

• Emergency Room
• No Charge after deductible if admitted; if not admitted -- limited to $250 per person per year
• Outpatient Lab/X-Ray
• No Charge after deductible if performed within 14 days of surgery or confinement
• Outpatient Surgery
• No Charge after deductible
• Hospitalization
• No Charge after deductible

Maternity Coverage

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

Additional Coverage

• Chiropractic Coverage
• Not Covered
• Mental Health Coverage
• Not Covered

Additional Information

• A.M. Best Rating
• A as of 06/15/2009
• 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