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Plan Type HMO
Office Visit for Primary Doctor
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N/A
Office Visit for Specialist N/A
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible None
Separate Prescription Drugs Deductible N/A
Coinsurance None
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit $0
Lifetime Maximum N/A
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage  
Office Visit
Primary Care Physician Required N/A
Specialist Referrals Required N/A
Preventive Care Coverage
Periodic Health Exam N/A
Periodic OB-GYN Exam N/A
Well Baby Care N/A
Emergency and Urgent Care
Emergency Room N/A
Emergency Ambulance Services $100 Copay
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible N/A
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery $50 copay for each ambulatory surgical center visit.
$15 to $50 copay [or 20% of the cost] for each outpatient hospital facility visit.
Outpatient Lab/X-Ray N/A
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 Days 1 - 5: $25 copay per day.
Days 6 - 90: $0 copay per day.
$0 copay for each additional hospital day.
No limit to the number of days covered by the plan each hospital stay.
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 N/A
Labor & Delivery Hospital Stay N/A
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 N/A
Durable Medical Equipment N/A
Hospice You must get care from a Medicare-certified hospice.
Your plan will pay for a consultative visit before you select hospice.
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A- as of 01/11/2013
Electronic Signature for Application Available No
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.

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IMPORTANT NOTICES AND DISCLAIMERS

  • 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.