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Plan Type POS
Metal Level Bronze
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: $6,300
Separate Prescription Drugs Deductible Integrated Medical / Rx Deductible
Coinsurance 0% Coinsurance
Retail Prescription Drugs Tier 1 - Preferred Generic Drugs: No charge after deductible;
Tier 2- Preferred Brand Drugs: No charge after deductible;
Tier 3 - Non Preferred Brand/Generic Drugs: No charge after deductible;
Tier 4 - Preferred Specialty Drugs: No charge after deductible;
Tier 5 - Non Preferred Specialty Drugs: No charge after deductible
Annual Out-of-Pocket Limit Individual: $6,300
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 Emergency Care Only.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam $0 Copay
Periodic OB-GYN Exam $0 Copay
Well Baby Care $0 Copay
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 Tier 1 - Preferred Generic Drugs: No charge after deductible;
Tier 2- Preferred Brand Drugs: No charge after deductible;
Tier 3 - Non Preferred Brand/Generic Drugs: No charge after deductible;
Tier 4 - Preferred Specialty Drugs: No charge after deductible;
Tier 5 - Non Preferred Specialty Drugs: No charge after deductible
Separate Prescription Drugs Deductible Integrated Medical / Rx Deductible
Mail Order Prescription Drugs Tier 1 - Preferred Generic Drugs: No charge after deductible;
Tier 2- Preferred Brand Drugs: No charge after deductible;
Tier 3 - Non Preferred Brand/Generic Drugs: No charge after deductible;
Tier 4 - Preferred Specialty Drugs: No charge after deductible;
Tier 5 - Non Preferred Specialty Drugs: No charge after deductible
Mail Order Supply 90
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
Inpatient Coverage
Hospitalization No charge after deductible
Skilled Nursing Facility No charge after deductible
Inpatient Mental Health No charge after deductible
Inpatient Substance Abuse No charge after deductible
Home Healthcare No charge after deductible
Maternity Coverage
Pre & Postnatal Office Visit $0 Copay
Labor & Delivery Hospital Stay No charge after deductible
Pediatric Services
Dental Checkup for Children $0 Copay
Vision Screening for Children No charge. Exam as needed when provided by opthalmologists and optometrists
Eye Glasses for Children No charge. Three pairs of standard eyeglass lenses or contact lenses per year; up to three frames per year
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage No charge after deductible
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 $6,400/$ 12,800
Out-of-Network Annual Coinsurance 50%
Out-of-Network Annual Out-of-Pocket Limit Unlimited
Additional Information
A.M. Best Rating A as of 06/19/2014
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.

Carrier specific notices, disclaimers and fees

  • Coventry Health Care of Kansas Inc. - To be eligible to enroll in catastrophic plans; individuals must be under the age of 30 prior to the first day of the contract year or have received a certificate of exemption from the government.