Premier $5000 Deductible Plan

Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• $40 Copay
• Office Visit for Specialist
• $50 Copay
• Coinsurance
• 30% after deductible
• Annual Deductible
• Individual:$5,000
• Separate Prescription Drugs Deductible
• $500 Individual
  $1,000 Family
  applies to
  Brand, Non-Formulary
• Prescription Drugs
• Generic: $15 Copay
• Brand: $30 Copay after deductible
• Non-Formulary: $50 Copay after deductible
• Annual Out-of-Pocket Limit
• Individual:$8,000
  Includes deductible
• Lifetime Maximum
• Unlimited
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• Yes. Paid at Out-of-Network benefit level 

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• No Charge
• Periodic OB-GYN Exam
• No Charge
• Well Baby Care
• No Charge

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay
• Brand Prescription Drugs
• $30 Copay after deductible
• Non-Formulary Prescription Drugs Coverage
• $50 Copay after deductible
• Mail Order for Prescription Drugs
• Generic: $30 Copay
• Brand: $60 Copay after deductible
• Non-Formulary: $100 Copay after deductible
• Days Supply: 60
• Separate Prescription Drugs Deductible
• $500 Individual
  $1,000 Family
  applies to
  Brand, Non-Formulary

Hospital Services Coverage

• Emergency Room
• $100 Copay (waived if admitted) plus 30% Coinsurance after deductible
• Outpatient Lab/X-Ray
• Non-preventive: 30% after deductible
• Outpatient Surgery
• 30% after deductible
• Hospitalization
• 30% after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not covered (except for pregnancy complications)
• Labor & Delivery Hospital Stay
• Not covered (except for pregnancy complications)

Additional Coverage

• Chiropractic Coverage
• 30% Coinsurance after deductible.
  24 Visits Per Year./$25 Max.
  Per Visit
• Mental Health Coverage
• 30% Coinsurance after deductible.
  Unlimited Days and Visits

Additional Information

• A.M. Best Rating
• A as of 08/21/2012
• 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
  Summary of Benefits & Coverage (Not available)
  The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Action

• Get live professional advice about this insurance plan
• Get Live Advice