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Plan Type PPO
Office Visit for Primary Doctor
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$20 Copay
Office Visit for Specialist $40 Copay after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $20 Copay
Annual Deductible Individual: $5,750
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 0%
Retail Prescription Drugs Generic Drugs: $10 Copay
Brand Name Drugs: $75 Copay after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Specialty Drugs: $250 Copay after deductible
Off Label Prescription Drugs: 50% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $6,350
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 Coverage for Emergency Care Only.
Office Visit
Primary Care Physician 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
Emergency and Urgent Care
Emergency Room $250 Copay after deductible
Emergency Ambulance Services $100 Copay after deductible
Urgent Care Facility $60 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $10 Copay
Brand Name Drugs: $75 Copay after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Specialty Drugs: $250 Copay after deductible
Off Label Prescription Drugs: 50% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: $30 Copay
Brand Name Drugs: $225 Copay after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Specialty Drugs: $750 Copay after deductible
Off Label Prescription Drugs: 50% Coinsurance after deductible
Mail Order Supply 31-90 days supply
Outpatient Coverage
Outpatient Surgery $100 Copay after deductible
Outpatient Lab/X-Ray Lab:0% Coinsurance after deductible/X-ray:$100 Copay after deductible
Imaging (CT and PET scans, MRIs) $250 Copay after deductible
Outpatient Mental Health $40 Copay after deductible
Outpatient Substance Abuse $40 Copay after deductible
Outpatient Rehabilitation Services (PT, OT, ST) $40 Copay after deductible, 35 Visit(s) per Year
Inpatient Coverage
Hospitalization $100 Copay per Stay, 0% Coinsurance after deductible
Skilled Nursing Facility $100 Copay per Stay, 0% Coinsurance after deductible, 25 Days per Year
Inpatient Mental Health $100 Copay after deductible
Inpatient Substance Abuse $100 Copay after deductible
Home Healthcare $40 Copay after deductible, 60 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit 0% Coinsurance after deductible
Labor & Delivery Hospital Stay $100 Copay after deductible
Pediatric Services
Dental Checkup for Children 0% Coinsurance, 2 Exam(s) per Year
Vision Screening for Children $0 Copay, 1 Exam(s) per Year
Eye Glasses for Children $0 Copay, 1 Item(s) per Year
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage $40 Copay after deductible, 35 Visit(s) per Year
Durable Medical Equipment 50% Coinsurance after deductible
Hospice $100 Copay after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) $0 Copay, 1 Exam(s) per Year
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $11500/$23000
Out-of-Network Annual Coinsurance 50%
Out-of-Network Annual Out-of-Pocket Limit $12700/$25400
Additional Information
A.M. Best Rating A as of 06/13/2013
Electronic Signature for Application Available Yes
Policy Form Number 63.06.311.1-TX (1/14)
Details and documents about this plan
View 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.

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IMPORTANT NOTICES AND DISCLAIMERS

  • THE BENEFITS MATRIX IS A SUMMARY FOR INFORMATIONAL PURPOSES ONLY. REVIEW THE EVIDENCE OF COVERAGE AND INSURANCE POLICY (PLAN CONTRACT) FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS, LIMITATIONS, AND EXCLUSIONS. ONLY THE TERMS AND CONDITIONS OF COVERAGE BENEFITS LISTED IN THE POLICY ARE BINDING.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • 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.