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Plan Type HMO
Office Visit for Primary Doctor
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First 2 office visits $40, then 20% after deductible
Office Visit for Specialist 20% after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) First 2 office visits $40, then 20% after deductible
Annual Deductible Individual: $5,750
Separate Prescription Drugs Deductible Medical Plan Deductible Applies to Tier 3 & 4
Coinsurance 20% after deductible
Retail Prescription Drugs Tier 1: $20 copay
Tier 2: $50 copay
Tier 3-4: 20% 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 Emergency Care Only 
Out-of-Country Coverage 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 $200 copay before deductible then 20% after deductible; waive copay if admitted
Emergency Ambulance Services 20% after deductible
Urgent Care Facility $50 copay before deductible then 20% after deductible
Prescription Drug Coverage
Retail Prescription Drugs Tier 1: $20 copay
Tier 2: $50 copay
Tier 3-4: 20% after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies to Tier 3 & 4
Mail Order Prescription Drugs Tier 1: $40 copay
Tier 2:$125 copay
Tier 3-4: 20% after deductible
Tier 1-2: 90 days maximum;
Tier 3-4: 30 days maximum
Mail Order Supply 30/90
Outpatient Coverage
Outpatient Surgery 20% after deductible
Outpatient Lab/X-Ray 20% after deductible
Imaging (CT and PET scans, MRIs) 20% after deductible
Outpatient Mental Health 20% after deductible
Outpatient Substance Abuse 20% after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 20% after deductible.
Limit to 20 visits per year
Inpatient Coverage
Hospitalization $500 inpatient copay per admission then 20% after deductible
Skilled Nursing Facility 20% after deductible.
Limit to 90 visits per year
Inpatient Mental Health 20% after deductible
Inpatient Substance Abuse 20% after deductible
Home Healthcare 20% after deductible.
Limit to 100 visits per year
Maternity Coverage
Pre & Postnatal Office Visit $500 inpatient copay per admission then 20% after deductible
Labor & Delivery Hospital Stay $500 inpatient copay per admission then 20% after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children $0 copay (Once every calendar year)
Eye Glasses for Children $0 copay (Once every calendar year)
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 20% after deductible.
Limit to 20 visits per year
Durable Medical Equipment 20% after deductible
Hospice 20% after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
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 A as of 06/06/2014
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.