Autograph Share 80/5000 Plus Rx & Doctor Visit Copay Health Insurance Plan Details

	Autograph Share 80/5000 Plus Rx & Doctor Visit Copay

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
$35 copay for GP's , then 0% coinsurance, limited to 6 combined (GP and Spec) visits per year. After 6 visits are met, then 20% coinsurance after deductible.
Office Visit for Specialist
$50 copay for Specialist's, then 0% coinsurance, limited to 6 combined (GP and Spec) visits per year. After 6 visits are met, then 20% coinsurance after deductible.
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.

Periodic Health Exam
20% Coinsurance/ No Deductible to $300/ Calendar Year Preventive Care Maximum
NO Waiting Period
Periodic OB-GYN Exam
Exam/Pap Smear/Mammogram: 20% Coinsurance/ No Deductible to $300/Calendar Year Preventive Care Maximum
No Waiting Period
Well Baby Care
20% Coinsurance/ No Deductible to $300/ Calendar Year Preventive Care Maximum
No Waiting Period

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

Chiropractic Coverage
20% Coinsurance after deductible. 20 Visits/ Calendar Year
(Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Mental Health Coverage
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)
No waiting period