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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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20% coinsurance after deductible
Office Visit for Specialist 20% coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) 20% coinsurance after deductible
Annual Deductible Individual: $2,500
Separate Prescription Drugs Deductible Medical plan deductible applies to all drugs
Coinsurance 20% coinsurance, subject to deductible
Retail Prescription Drugs Tier 1: 20% coinsurance after deductible; Tier 2: 20% coinsurance after deductible; Tier 3 (Specialty): 20% coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $4,100
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 Yes. Covered as any other non-contracted provider 
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 20% coinsurance after deductible
Emergency Ambulance Services 20% coinsurance after deductible
Urgent Care Facility 20% coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Tier 1: 20% coinsurance after deductible; Tier 2: 20% coinsurance after deductible; Tier 3 (Specialty): 20% coinsurance after deductible
Separate Prescription Drugs Deductible Medical plan deductible applies to all drugs
Mail Order Prescription Drugs Tier 1: 20% coinsurance after deductible; Tier 2: 20% coinsurance after deductible; Tier 3 (Specialty): retail only at specific pharmacies
Mail Order Supply 90 day supply
Outpatient Coverage
Outpatient Surgery 20% coinsurance after deductible
Outpatient Lab/X-Ray 20% coinsurance after deductible
Imaging (CT and PET scans, MRIs) 20% coinsurance after deductible
Outpatient Mental Health 20% coinsurance after deductible
Outpatient Substance Abuse 20% coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 20% coinsurance after deductible; Maximum 25 visits per calendar year
Inpatient Coverage
Hospitalization 20% coinsurance after deductible
Skilled Nursing Facility 20% coinsurance after deductible; Maximum 60 days per calendar year
Inpatient Mental Health 20% coinsurance after deductible
Inpatient Substance Abuse 20% coinsurance after deductible
Home Healthcare 20% coinsurance after deductible; Maximum 130 visits per calendar year
Maternity Coverage
Pre & Postnatal Office Visit 20% coinsurance after deductible
Labor & Delivery Hospital Stay 20% coinsurance after deductible
Pediatric Services
Dental Checkup for Children 10% coinsurance after deductible
Vision Screening for Children 20% coinsurance, deductible waived
Eye Glasses for Children No charge. 1 pair of contacts or lenses per calendar year. 1 pair of frames per calendar year.
Major Dental Coverage (Pediatric) Covered-see brochure
Additional Coverage
Chiropractic Coverage 20% coinsurance after deductible; Maximum 10 visits per calendar year
Durable Medical Equipment 20% coinsurance after deductible
Hospice 20% coinsurance after deductible
Major Dental Coverage (Adult) Not covered
Vision Coverage (Adult) Not covered
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $5000/$10000
Out-of-Network Annual Coinsurance 50% coinsurance after deductible
Out-of-Network Annual Out-of-Pocket Limit Unlimited
Additional Information
A.M. Best Rating A- as of 06/07/2013
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.