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Plan Type POS
Office Visit for Primary Doctor
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$30 copay for the first 3 visits, per member per year, not subject to deductible. After 3 visits, once deductible is met, then 30%
Office Visit for Specialist $30 copay for the first 3 visits, per member per year, not subject to deductible. After 3 visits, once deductible is met, then 30%
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $1,500
Separate Prescription Drugs Deductible None
Coinsurance 30% after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $4,500
Includes deductible
Lifetime Maximum $5 Million per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider  (View Details)
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam $30 copay for the first 3 visits, per member per year, not subject to deductible. After 3 visits, once deductible is met, then 30%
Periodic OB-GYN Exam 30% Coinsurance after deductible
Well Baby Care 30% Not subject to deductible
Emergency and Urgent Care
Emergency Room $500 copay; waived if admitted
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs N/A
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 30% Coinsurance after deductible
Outpatient Lab/X-Ray 30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 30% Coinsurance after deductible
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Not Covered, except for complications
Labor & Delivery Hospital Stay Not Covered, except for complications
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage 30% Coinsurance after deductible
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
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 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.