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Plan Type PPO
Office Visit for Primary Doctor
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40% Coinsurance after deductible
Office Visit for Specialist 40% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) 40% Coinsurance after deductible
Annual Deductible Individual: $4,500
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 40%
Retail Prescription Drugs Generic Drugs: 40% Coinsurance after deductible
Brand Name Drugs: 40% Coinsurance after deductible
Non-Formulary Drugs: 40% Coinsurance after deductible
Specialty Drugs: 40% Coinsurance 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 Yes  (Details in plan brochure below)
Out-of-Country Coverage No.
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 40% Coinsurance after deductible
Emergency Ambulance Services 40% Coinsurance after deductible
Urgent Care Facility 40% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: 40% Coinsurance after deductible
Brand Name Drugs: 40% Coinsurance after deductible
Non-Formulary Drugs: 40% Coinsurance after deductible
Specialty Drugs: 40% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: 40% coinsurance after deductible
Preferred brand drugs: 40% coinsurance after deductible
Non-preferred brand drugs: 40% coinsurance after deductible
Mail Order Supply 90-Day supply
Outpatient Coverage
Outpatient Surgery 40% Coinsurance after deductible
Outpatient Lab/X-Ray 40% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 40% Coinsurance after deductible
Outpatient Mental Health 40% Coinsurance after deductible
Outpatient Substance Abuse 40% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 40% Coinsurance after deductible
Inpatient Coverage
Hospitalization 40% Coinsurance after deductible
Skilled Nursing Facility 40% Coinsurance after deductible, 100 Days per Benefit Period
Inpatient Mental Health 40% Coinsurance after deductible
Inpatient Substance Abuse 40% Coinsurance after deductible
Home Healthcare 40% Coinsurance after deductible, 100 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay 40% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children No Charge. Applies to age 1-19.
Vision Screening for Children No Charge, 1 Visit(s) per Year
Eye Glasses for Children No Charge, 1 Item(s) per Year
Major Dental Coverage (Pediatric) Pediatric Dental bundled with medical plan. $365 Copay after $0 dental deductible.
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 40% Coinsurance after deductible
Hospice No Charge after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $4,500 individual/$9,000 family (combined with In-network)
Out-of-Network Annual Coinsurance 50% after deductible
Out-of-Network Annual Out-of-Pocket Limit $9,350 individual/$18,700 family
Additional Information
A.M. Best Rating A as of 04/17/2014
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure

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.