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Plan Type POS
Metal Level Platinum
Office Visit for Primary Doctor
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$15 Copay
Office Visit for Specialist $30 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $15 Copay
Annual Deductible None
Separate Prescription Drugs Deductible $0 Individual/$0 Family
Coinsurance 0%
Retail Prescription Drugs Tier $0- Flu, Shingle, and Generic and Select Oral Contraceptives;
Tier 1 (Generic Preferred)- $3;
Tier 2 (Generic Non-Preferred)- $5;
Tier 3 (Brand Preferred)- $25;
Tier 4 (Brand Non-Preferred)-$50;
Tier 5 (Specialty)-40% up to $150
Annual Out-of-Pocket Limit Individual: $3,000
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Emergent and urgent care. 
Office Visit
Primary Care Physician Required Yes
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 $200 Copay
Emergency Ambulance Services $150 Copay
Urgent Care Facility $30 Copay
Prescription Drug Coverage
Retail Prescription Drugs Tier $0- Flu, Shingle, and Generic and Select Oral Contraceptives;
Tier 1 (Generic Preferred)- $3;
Tier 2 (Generic Non-Preferred)- $5;
Tier 3 (Brand Preferred)- $25;
Tier 4 (Brand Non-Preferred)-$50;
Tier 5 (Specialty)-40% up to $150
Separate Prescription Drugs Deductible $0 Individual/$0 Family
Mail Order Prescription Drugs Tier 1 (Generic Preferred)- $6;
Tier 2 (Generic Non-Preferred)- $10;
Tier 3 (Brand Preferred)- $50;
Tier 4 (Brand Non-Preferred)-$100
Mail Order Supply 90-Day supply
Outpatient Coverage
Outpatient Surgery $250 Copay after deductible
Outpatient Lab/X-Ray $0 Copay
Imaging (CT and PET scans, MRIs) $250 Copay after deductible
Outpatient Mental Health $15 Copay
Outpatient Substance Abuse $30 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $30 Copay, 30 Visit(s) per Year
Inpatient Coverage
Hospitalization $500 Copay per Stay
Skilled Nursing Facility $50 Copay per Day, 120 Days per Year
Inpatient Mental Health $500 Copay after deductible
Inpatient Substance Abuse $500 Copay after deductible
Home Healthcare $15 Copay, 60 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit $0 Copay
Labor & Delivery Hospital Stay $500 Copay after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children $30 Copay, 1 Visit(s) per Year
Eye Glasses for Children 50% Coinsurance after deductible, 1 Item(s) per 2 Years
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $15 Copay, 20 Visit(s) per Year
Durable Medical Equipment $0 Copay, 20% Coinsurance after deductible
Hospice $30 Copay, 0% Coinsurance
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) $30
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $2,000/$4,000
Out-of-Network Annual Coinsurance 20%
Out-of-Network Annual Out-of-Pocket Limit $10,000/$20,000
Additional Information
A.M. Best Rating NR-5 as of 08/26/2009
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure 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.