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Plan Type PPO
Office Visit for Primary Doctor
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$30 Copay
Office Visit for Specialist $60 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $60 Copay
Annual Deductible None
Separate Prescription Drugs Deductible None
Coinsurance 30%
Retail Prescription Drugs Preferred Generic: $4 Copay
Non-preferred Generic: $25 Copay
Preferred Brand: $60 Copay
Non-preferred Brand: 50% Coinsurance
Specialty: 40% 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. 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 $500 Copay
Emergency Ambulance Services $500 Copay
Urgent Care Facility $75 Copay
Prescription Drug Coverage
Retail Prescription Drugs Preferred Generic: $4 Copay
Non-preferred Generic: $25 Copay
Preferred Brand: $60 Copay
Non-preferred Brand: 50% Coinsurance
Specialty: 40% Coinsurance
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs Preferred Generic: $10 Copay
Non-preferred Generic: $62 Copay
Preferred Brand: $150 Copay
Non-preferred Brand: 50% Coinsurance
Specialty: 30% Coinsurance
Mail Order Supply 90, except specialty which will be 30
Outpatient Coverage
Outpatient Surgery $2,000 Copay
Outpatient Lab/X-Ray 40% Coinsurance
Imaging (CT and PET scans, MRIs) $750 Copay
Outpatient Mental Health $60 Copay
Outpatient Substance Abuse $60 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $60 Copay (35 visits/year combined in and out of network)
Inpatient Coverage
Hospitalization $2,000 per day
Skilled Nursing Facility $300 per day (Calendar year maximum of 25 days, combined in- and out-of-network)
Inpatient Mental Health $2,000 per day
Inpatient Substance Abuse $2,000 per day
Home Healthcare $100 per day (Calendar year maximum of 60 visits, combined in- and out-of-network)
Maternity Coverage
Pre & Postnatal Office Visit 30% Coinsurance
Labor & Delivery Hospital Stay $2,000 per day
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 $60 Copay (Calendar year maximum of 35 visits, combined in- and out-of-network)
Durable Medical Equipment 30% Coinsurance
Hospice 30% Coinsurance
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 865711 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.