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Plan Type EPO
Metal Level Silver
Office Visit for Primary Doctor
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$50 Copay after deductible
Office Visit for Specialist $75 Copay after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $50 Copay after deductible
Annual Deductible Individual: $1,350
Separate Prescription Drugs Deductible Medical Plan Deductible Applies except Generic Drugs
Coinsurance 50%
Retail Prescription Drugs Generic Drugs: $7 Copay
Brand Name Drugs: 50% Coinsurance after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Specialty Drugs: 50% Coinsurance after deductible
Off Label Prescription Drugs: 50% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $5,100
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage No.
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 $100 Copay after deductible
Emergency Ambulance Services 50% Coinsurance after deductible
Urgent Care Facility $75 Copay after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $7 Copay
Brand Name Drugs: 50% Coinsurance after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Specialty Drugs: 50% Coinsurance after deductible
Off Label Prescription Drugs: 50% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies except Generic Drugs
Mail Order Prescription Drugs Generic Drugs: $14 Copay
Brand Name Drugs: 50% Coinsurance after deductible
Non-Formulary Drugs: 50% Coinsurance after deductible
Mail Order Supply 90 day supply
Outpatient Coverage
Outpatient Surgery 50% Coinsurance after deductible
Outpatient Lab/X-Ray 50% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 50% Coinsurance after deductible
Outpatient Mental Health $75 Copay after deductible
Outpatient Substance Abuse $75 Copay after deductible
Outpatient Rehabilitation Services (PT, OT, ST) $75 Copay after deductible, 30 Visit(s) per Year
Inpatient Coverage
Hospitalization 10% Coinsurance after deductible
Skilled Nursing Facility $100 Copay per Day
Inpatient Mental Health 10% Coinsurance after deductible
Inpatient Substance Abuse 10% Coinsurance after deductible
Home Healthcare 50% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay 10% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge after deductible, 1 Visit(s) per Year
Eye Glasses for Children No Charge after deductible, 1 Item(s) per Year
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $75 Copay after deductible, 30 Visit(s) per Year
Durable Medical Equipment 50% Coinsurance after deductible
Hospice 50% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) No Charge
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating NR-5 as of 04/09/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. 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 form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. 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.