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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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$25 Copay
Office Visit for Specialist $60 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $25 Copay
Annual Deductible Individual: $2,500
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 20%
Retail Prescription Drugs Generic Drugs: $15 Copay, 34 Days per Month
Brand Name Drugs: $55 Copay, 34 Days per Month
Non-Preferred Brand Drugs: $90 Copay, 34 Days per Month
Specialty Drugs: $200 Copay, 1 Treatment(s) per Month
Off Label Prescription Drugs: 20% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $6,300
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. Emergency Care 
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 $150 Copay
Emergency Ambulance Services 20% Coinsurance after deductible
Urgent Care Facility 20% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $15 Copay, 34 Days per Month
Brand Name Drugs: $55 Copay, 34 Days per Month
Non-Preferred Brand Drugs: $90 Copay, 34 Days per Month
Specialty Drugs: $200 Copay, 1 Treatment(s) per Month
Off Label Prescription Drugs: 20% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Not Covered
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery 30% Coinsurance after deductible
Outpatient Lab/X-Ray $0 Copay
Imaging (CT and PET scans, MRIs) $150 Copay
Outpatient Mental Health $25 Copay
Outpatient Substance Abuse $25 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $25 Copay
Inpatient Coverage
Hospitalization $200 Copay per Day
Skilled Nursing Facility $200 Copay per Day, 60 Visit(s) per Year
Inpatient Mental Health $200 Copay
Inpatient Substance Abuse $200 Copay
Home Healthcare 20% Coinsurance after deductible, 50 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit 20% Coinsurance after deductible
Labor & Delivery Hospital Stay 20% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children 20% Coinsurance after deductible, 1 Visit(s) per Year
Eye Glasses for Children 20% Coinsurance after deductible, 1 Item(s) per Year
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $25 Copay
Durable Medical Equipment $25 Copay
Hospice 20% Coinsurance after deductible
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) No Charge, 1 Visit(s) per 2 Years
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $5000/$10000
Out-of-Network Annual Coinsurance 40% Coinsurance after deductible
Out-of-Network Annual Out-of-Pocket Limit $12600/$25000
Additional Information
A.M. Best Rating A as of 10/02/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure (Not available)

The carrier has not provided a separate document for 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.