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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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50% Coinsurance
Office Visit for Specialist 50% Coinsurance
Office Visit for Other Practitioner (Nurse, Physician Assistant) 50% Coinsurance
Annual Deductible None
Separate Prescription Drugs Deductible None
Coinsurance 50%
Retail Prescription Drugs Generic Drugs: 50% Coinsurance
Brand Name Drugs: 50% Coinsurance
Non-Formulary Drugs: 50% Coinsurance
Specialty Drugs: 50% Coinsurance
Annual Out-of-Pocket Limit Individual: $6,350
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. The benefits available under this Contract are also available to Members traveling or living outside the United States. The Inpatient Notification and Prior Authorization requirements will apply. 
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, then 50% coinsurance
Emergency Ambulance Services 50% Coinsurance
Urgent Care Facility 50% Coinsurance
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: 50% Coinsurance
Brand Name Drugs: 50% Coinsurance
Non-Formulary Drugs: 50% Coinsurance
Specialty Drugs: 50% Coinsurance
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs Generic Drugs: 50% Coinsurance
Brand Name Drugs: 50% Coinsurance
Non-Formulary Drugs: 50% Coinsurance
Specialty Drugs: 50% Coinsurance
Mail Order Supply 90-Day supply
Outpatient Coverage
Outpatient Surgery 50% Coinsurance
Outpatient Lab/X-Ray 50% Coinsurance
Imaging (CT and PET scans, MRIs) $250 copay, then 50% coinsurance
Outpatient Mental Health 50% Coinsurance
Outpatient Substance Abuse 50% Coinsurance
Outpatient Rehabilitation Services (PT, OT, ST) 50% Coinsurance, limited to a combined PT, ST, OT total of 20 visits per member per benefit period.
Inpatient Coverage
Hospitalization $0 Copay per Day, 50% Coinsurance
Skilled Nursing Facility $0 Copay per Day, 50% Coinsurance, 30 days per member per benefit period
Inpatient Mental Health 50% Coinsurance
Inpatient Substance Abuse 50% Coinsurance
Home Healthcare 50% Coinsurance
Maternity Coverage
Pre & Postnatal Office Visit 50% Coinsurance
Labor & Delivery Hospital Stay 50% Coinsurance
Pediatric Services
Dental Checkup for Children Not Covered (Stand alone pediatric and adult dental plans available)
Vision Screening for Children No Charge, 1 Exam(s) per Benefit Period
Eye Glasses for Children No Charge, 1 Item(s) per Benefit Period
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 50% Coinsurance, 18 visits per member per benefit period
Durable Medical Equipment 50% Coinsurance
Hospice No Charge
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $1000/$2000
Out-of-Network Annual Coinsurance 50% after deductible
Out-of-Network Annual Out-of-Pocket Limit $8350/$16700
Additional Information
A.M. Best Rating N/A as of 11/14/2014
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.

Customer reviews

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.