ClearProtection Plus 3300

Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• First 2 Office Visits (per member): $40 copay, deductible waived
  Additional Office Visits: 100% of negotiated fee;
  then 0% Coinsurance after out-of-pocket maximum is met
• Office Visit for Specialist
• First 2 Office Visits (per member): $40 copay, deductible waived
  Additional Office Visits: 100% of negotiated fee;
  then 0% Coinsurance after out-of-pocket maximum is met
• Coinsurance
• 40% after deductible
• Annual Deductible
• Individual:$3,300
• Separate Prescription Drugs Deductible
• $7,500 per member for Brand and Non-formulary drug only
• Prescription Drugs
• Generic: $15 Copay
• Brand: $40 Copay after $7,500 annual Prescription Drug deductible per member
• Non-Formulary: $60 Copay after $7,500 annual Prescription Drug deductible per member
• Annual Out-of-Pocket Limit
• Individual:$6,800
  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
• Emergency Care Only

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• 0% Coinsurance, not subject to deductible
• Periodic OB-GYN Exam
• 0% Coinsurance, not subject to deductible
• Well Baby Care
• 0% Coinsurance, not subject to deductible

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay
• Brand Prescription Drugs
• $40 Copay after $7,500 annual Prescription Drug deductible per member
• Non-Formulary Prescription Drugs Coverage
• $60 Copay after $7,500 annual Prescription Drug deductible per member
• Mail Order for Prescription Drugs
• Generic: $45 Copay
• Brand: $120 Copay after $7,500 annual Prescription Drug deductible per member
• Non-Formulary: Not Covered
• Days Supply: 90
• Separate Prescription Drugs Deductible
• $7,500 per member for Brand and Non-formulary drug only

Hospital Services Coverage

• Emergency Room
• 40% Coinsurance after deductible plus $100 Emergency Room copay (copay waived if admitted)
• Outpatient Lab/X-Ray
• Inpatient: 40% Coinsurance after deductible
  Outpatient: 100% of negotiated fee;
  then 0% Coinsurance after out-of-pocket maximum is met
• Outpatient Surgery
• 40% Coinsurance after deductible
• Hospitalization
• 40% Coinsurance 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
• Substance Abuse Coverage
• Not Covered

Out-of-Network Coverage

• Out-of-Network Authorization Required
• No
• Out-of-Network Deductible
• $3,300 individual/$6,600 family
• Out-of-Network Coinsurance
• 40% after deductible for Inpatient
  0% after deductible for outpatient
• Out-of-Network Out-of-Pocket Limit
• $6,800 individual/$13,600 family
  Includes deductible

Additional Information

• A.M. Best Rating
• A as of 07/10/2012
• 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

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