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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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No Charge after deductible
Office Visit for Specialist No Charge after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) No Charge after deductible
Annual Deductible Individual: $3,400
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 0% after deductible
Retail Prescription Drugs Preferred Generic: No Charge after deductible
Non-preferred Generic: No Charge after deductible
Preferred Brand: No Charge after deductible
Non-preferred Brand: 50% after deductible
Specialty: No Charge 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 Yes. All Services 
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 No Charge after deductible
Emergency Ambulance Services No Charge after deductible
Urgent Care Facility No Charge after deductible
Prescription Drug Coverage
Retail Prescription Drugs Preferred Generic: No Charge after deductible
Non-preferred Generic: No Charge after deductible
Preferred Brand: No Charge after deductible
Non-preferred Brand: 50% after deductible
Specialty: No Charge after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Preferred Generic: No Charge after deductible
Non-preferred Generic: No Charge after deductible
Preferred Brand: No Charge after deductible
Non-preferred Brand: 50% after deductible
Specialty: No Charge after deductible
Mail Order Supply 90, except specialty which will be 30
Outpatient Coverage
Outpatient Surgery No Charge after deductible
Outpatient Lab/X-Ray No Charge after deductible
Imaging (CT and PET scans, MRIs) No Charge after deductible
Outpatient Mental Health No Charge after deductible
Outpatient Substance Abuse No Charge after deductible
Outpatient Rehabilitation Services (PT, OT, ST) No Charge after deductible (35 visits/year combined in and out of network)
Inpatient Coverage
Hospitalization No Charge after deductible
Skilled Nursing Facility No Charge after deductible (Calendar year maximum of 25 days, combined in- and out-of-network)
Inpatient Mental Health No Charge after deductible
Inpatient Substance Abuse No Charge after deductible
Home Healthcare No Charge after deductible (Calendar year maximum of 60 visits, combined in- and out-of-network)
Maternity Coverage
Pre & Postnatal Office Visit No Charge after deductible
Labor & Delivery Hospital Stay No Charge after deductible
Pediatric Services
Dental Checkup for Children Pediatric Dental bundled with medical plan. No Charge after $50 dental deductible. Applies to ages 1-19.
Vision Screening for Children No Charge. Children up to age 19. Limited to 1 visit per 12 month period.
Eye Glasses for Children No Charge. Children up to age 19. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period.
Major Dental Coverage (Pediatric) Pediatric Dental bundled with medical plan. 50% Coinsurance after $50 dental deductible.
Additional Coverage
Chiropractic Coverage No Charge after deductible (Calendar year maximum of 35 visits, combined in- and out-of-network)
Durable Medical Equipment No Charge 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 No
Out-of-Network Annual Deductible $12,500 Individual/$25,000 Family
Out-of-Network Annual Coinsurance 50% after deductible
Out-of-Network Annual Out-of-Pocket Limit $25,000 Individual/$50,000 Family
Additional Information
A.M. Best Rating A as of 02/13/2014
Electronic Signature for Application Available Yes
Policy Form Number 865707 a TX 12/13
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.

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.

Carrier specific notices, disclaimers and fees

  • Cigna - These plans are intended to comply with the federal Patient Protection and Affordable Care Act (PPACA). Provisions are subject to change as additional regulatory guidance becomes available.