Evolve Plus

Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• $25 Copay for first 4 office visits primary/specialist, deductible and coinsurance after
• Office Visit for Specialist
• $25 Copay for first 4 office visits primary/specialist, deductible and coinsurance after
• Coinsurance
• 20% Coinsurance after deductible
• Annual Deductible
• Individual:$5,000
• Separate Prescription Drugs Deductible
• $500, Brand only
• Prescription Drugs
• Generic: $10 Copay $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Brand: 50%, 500 deductible, $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Non-Formulary: Not Covered
• Annual Out-of-Pocket Limit
• Individual:$5,500
  Does not include deductible
• Lifetime Maximum
• $2 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

Physicians

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

Preventive Care Coverage

• Periodic Health Exam
• 20% coinsurance deductible waived
• Periodic OB-GYN Exam
• 20% coinsurance deductible waived
• Well Baby Care
• 20% coinsurance deductible waived

Prescription Drug Coverage

• Generic Prescription Drugs
• $10 Copay $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Brand Prescription Drugs
• 50%, 500 deductible, $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Non-Formulary Prescription Drugs Coverage
• Not Covered
• Mail Order for Prescription Drugs
• Generic: $30 Copay $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Brand: 50%, 500 deductible, $2,500 per calendar year benefit maximum, generic and brand combined (does not include oral chemotherapy and smoking cessation drugs)
• Non-Formulary: Not Covered
• Days Supply: 90
• Separate Prescription Drugs Deductible
• $500, Brand only

Hospital Services Coverage

• Emergency Room
• Covered after deductible, $100 copay per visit (waived if admitted) and Category 1 coinsurance
• Outpatient Lab/X-Ray
• Covered at 100% (deductible waived) to upfront benefit of $400;
  then deductible and coinsurance apply (does not include preventive care and complex imaging)
• Outpatient Surgery
• 20% Coinsurance after deductible
• Hospitalization
• 20% Coinsurance after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• 20% Coinsurance after deductible
• Labor & Delivery Hospital Stay
• 20% Coinsurance after deductible

Additional Coverage

• Chiropractic Coverage
• (chiropractic, acupuncture, naturopathic services combined) Covered after deductible and coinsurance
• Mental Health Coverage
• Covered after deductible and coinsurance Inpatient: 6 days per calendar year.
  Outpatient: 12 visits per calendar year
• Substance Abuse Coverage
• Not Covered

Out-of-Network Coverage

• Out-of-Network Authorization Required
• No
• Out-of-Network Deductible
• Shared with In-network
• Out-of-Network Coinsurance
• 50% after deductible
• Out-of-Network Out-of-Pocket Limit
• Shared with In-network

Additional Information

• A.M. Best Rating
• A- as of 06/15/2012
• 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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