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Plan Type PPO
Office Visit for Primary Doctor
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$20 Copay
Office Visit for Specialist $40 Copay after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $1,250
Separate Prescription Drugs Deductible subject to medical deductible
Coinsurance No Charge after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: No Limit
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 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 $200 Copay (after annual deductible) waived if admitted
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible subject to medical deductible
Mail Order Prescription Drugs N/A
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 0% (after annual deductible)
Outpatient Lab/X-Ray Lab: 0% (after annual deductible); Diagnostic X-ray: 0% (after annual deductible)
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 0% (after annual deductible)
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Prenatal Visits: $20 Copay (first visit only) not subject to deductible; Other maternity services (includes diagnostic tests, delivery and other physician services): No charge after deductible. 9 month waiting period for all covered maternity svcs
Labor & Delivery Hospital Stay $2500 Copay (per admission) not subject to deductible. 9 month waiting period for all covered maternity svcs
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage $20 Copay (20 visits maximum)
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $2500/$5000
Out-of-Network Annual Coinsurance 30% after deductible
Out-of-Network Annual Out-of-Pocket Limit $10000/$20000
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 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

  • HealthAmerica Pennsylvania - 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.