Portrait Share 80/1000 Plus Rx & Unlimited Doctor Visit Copay

Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• $35 copay
• Office Visit for Specialist
• $50 copay
• Coinsurance
• 20% after deductible
• Annual Deductible
• Individual:$1,000
• Separate Prescription Drugs Deductible
• $500 Individual;
  Applies to Levels 2, 3, 4
• Prescription Drugs
• Rx Deductible for Levels 2, 3, 4 Level 1: $15 copay Level 2: $35 copay Level 3: $55 copay Level 4: 25% copay up to $2500 maximum out of pocket.
  Levels based on specific drug
• Annual Out-of-Pocket Limit
• Individual:$2,000
  Does not include deductible
• Lifetime Maximum
• $5 Million per person
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• Emergency Care Only. Paid as out-of-network, and member must submit an itemized bill with services rendered and a diagnosis in order to be reimbursed. 

Physicians

• Primary Care Physician (PCP) Required
• No
• Specialist Referrals Required
• No

Preventive Care Coverage

• Periodic Health Exam
• 20% Coinsurance/No Deductible
  to $300/Calendar Year Preventive Care Maximum
  90 Day Waiting Period
• Periodic OB-GYN Exam
• Exam: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum;
  90 Day Waiting Period
  Pap Smear: 20% Coinsurance/No Deductible;
  No Calendar Year Preventive Care Maximum;
  No Waiting Period
  Mammogram: 20% Coinsurance/No Deductible;
  Limited to 130% of medicare reimbursement rate maximum;
  No Calendar Year Preventive Care Maximum, No Waiting Period
• Well Baby Care
• Child Health Supervision Services
  Birth to age one: 20% Coinsurance/No Deductible to $500 calendar year maximum, no waiting period;
  Ages 1-8: 20% Coinsurance/No Deductible to $150 calendar year maximum, no waiting period;
  Ages 9-18: 20% Coinsurance/No Deductible to $300 calendar year maximum, 90 day waiting period.

Prescription Drug Coverage

• Prescription Drugs Other Coverage
• Rx Deductible for Levels 2, 3, 4 Level 1: $15 copay Level 2: $35 copay Level 3: $55 copay Level 4: 25% copay up to $2500 maximum out of pocket.
  Levels based on specific drug
• Mail Order for Prescription Drugs
• Rx Deductible for Levels 2, 3, 4
  Level 1: $45 copay
  Level 2: $105 copay
  Level 3: $165 copay
  Level 4: 75% copay up to $2500 maximum out of pocket.
  Levels based on specific drug
• Days Supply: 90
• Separate Prescription Drugs Deductible
• $500 Individual;
  Applies to Levels 2, 3, 4

Hospital Services Coverage

• Emergency Room
• $75 Copay (waived if admitted) plus 20% Coinsurance after deductible
• Outpatient Lab/X-Ray
• First $200 per cal year at 0% Coinsurance, then 20% Coinsurance after deductible
• Outpatient Surgery
• 20% Coinsurance after deductible
• Hospitalization
• 20% Coinsurance after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not Covered
• Labor & Delivery Hospital Stay
• Not Covered

Additional Coverage

• Chiropractic Coverage
• 20% Coinsurance after deductible
  20 Visits/Calendar Year
  (Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
• Mental Health Coverage
• 50% Coinsurance after deductible
  $2500/Calendar Year Maximum.
  Outpatient care not to exceed $500 of the $2500 Calendar Year Maximum;
  (Combined Mental Disorders/Alcohol and Chemical Dependence Calendar Year Max)
  One year waiting period

Additional Information

• A.M. Best Rating
• A- as of 01/11/2013
• Electronic Signature for Application Available
• Yes
• Will insurance company obtain and pay for medical records?
• Yes
• Additional information about this health insurance plan is available in the documents below.
  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.

Action

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