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Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
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$60 a visit for a total of three primary, urgent, or outpatient mental health care visits. Additional visits $60 after deductible.
Office Visit for Specialist $70 copay after deductible per visit
Office Visit for Other Practitioner (Nurse, Physician Assistant) $60 copay after deductible per visit
Annual Deductible Individual: $5,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 30% Coinsurance after deductible
Retail Prescription Drugs Generic Drugs: $19 Copay; Brand Drugs: $50 Copay; Non-Formulary Drugs: $50 Copay
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 $300 after deductible (waived if admitted)
Emergency Ambulance Services $300 Copay
Urgent Care Facility $60 a visit for a total of three primary, urgent, or outpatient mental health care visits. Additional visits $60 after deductible.
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $19 Copay; Brand Drugs: $50 Copay; Non-Formulary Drugs: $50 Copay
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: $38 Copay; Brand Drugs: $100 Copay; Non-Formulary Drugs: $100 Copay
Mail Order Supply 100-day supply
Outpatient Coverage
Outpatient Surgery 30% coinsurance after deductible per procedure
Outpatient Lab/X-Ray 30% coinsurance after deductible per procedure
Imaging (CT and PET scans, MRIs) 30% coinsurance after deductible per procedure
Outpatient Mental Health $60 a visit for a total of three primary, urgent, or outpatient mental health care visits. Additional visits $60 after deductible.
Outpatient Substance Abuse $60 a visit for a total of three primary, urgent, or outpatient mental health care visits. Additional visits $60 after deductible.
Outpatient Rehabilitation Services (PT, OT, ST) 30% coinsurance after deductible
Inpatient Coverage
Hospitalization 30% coinsurance after deductible
Skilled Nursing Facility 30% coinsurance after deductible
Inpatient Mental Health 30% coinsurance after deductible
Inpatient Substance Abuse 30% coinsurance after deductible
Home Healthcare No Charge
Maternity Coverage
Pre & Postnatal Office Visit Routine Prenatal Care: no charge. Postnatal Care: no charge first post partum visit.
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 (1 pair per calendar year)
Major Dental Coverage (Pediatric) Crowns & Casts, Prosthodontics, Endodontics, Periodontics, Oral Surgery: $365 Copay
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 30% coinsurance after deductible
Hospice No Charge
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 05/07/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure 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.