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Plan Type HMO
Metal Level Silver
Office Visit for Primary Doctor
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$35 Copay
Office Visit for Specialist $70 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 Copay
Annual Deductible Individual: $2,000
Separate Prescription Drugs Deductible None
Coinsurance 30%, subject to deductible
Retail Prescription Drugs Generic Drugs: $10 Copay
Brand Name Drugs: 50% Coinsurance ($250 Copay max per prescription)
Non-Formulary Drugs: 50% Coinsurance ($250 Copay max per prescription)
Annual Out-of-Pocket Limit Individual: $6,350
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Emergency Care Only.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
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 30% Coinsurance after deductible
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility 30% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $10 Copay
Brand Name Drugs: 50% Coinsurance ($250 Copay max per prescription)
Non-Formulary Drugs: 50% Coinsurance ($250 Copay max per prescription)
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs Generic Drugs: $20 Copay
Brand Name Drugs: 50% Coinsurance ($500 Copay max per prescription)
Non-Formulary Drugs: 50% Coinsurance ($500 Copay max per prescription)
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 30% Coinsurance after deductible
Outpatient Lab/X-Ray Lab: No Charge; X-Ray: $60 Copay
Imaging (CT and PET scans, MRIs) $250 Copay
Outpatient Mental Health $70 Copay
Outpatient Substance Abuse $70 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $60 Copay; 30 Visits Per Year
Inpatient Coverage
Hospitalization 30% Coinsurance after deductible
Skilled Nursing Facility 30% Coinsurance after deductible; Maximum Stay 120 Days
Inpatient Mental Health 30% Coinsurance after deductible
Inpatient Substance Abuse 30% Coinsurance after deductible
Home Healthcare 30% Coinsurance after deductible; 60 Visits Per Year
Maternity Coverage
Pre & Postnatal Office Visit $70 Copay
Labor & Delivery Hospital Stay 30% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children No Charge
Vision Screening for Children No charge
Eye Glasses for Children No charge
Major Dental Coverage (Pediatric) 50% Coinsurance after $50 dental deductible
Additional Coverage
Chiropractic Coverage 30% Coinsurance after deductible; 20 Visits Per Year
Durable Medical Equipment 50% Coinsurance after deductible
Hospice 30% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
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 NR-5 as of 04/07/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure (Not available) Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. 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 form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. 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.