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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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20% Coinsurance before deductible
Office Visit for Specialist 20% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) 20% Coinsurance after deductible.
Coverage is limited to 12 acupuncture visits / year, 10 spinal manipulations / year.
Annual Deductible Individual: $3,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 20% Coinsurance, subject to deductible
Retail Prescription Drugs Generic Drugs: $10 copay before deductible
Brand Name Drugs: 30% Coinsurance
Non-Formulary Drugs: Not covered
Annual Out-of-Pocket Limit Individual: $4,900
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.
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 after $200 copay
Emergency Ambulance Services 20% Coinsurance after deductible
Urgent Care Facility 20% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $10 copay before deductible
Brand Name Drugs: 30% Coinsurance
Non-Formulary Drugs: Not covered
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: $20 copay before deductible
Brand Name Drugs: 25% Coinsurance
Non-Formulary Drugs: Not covered
Mail Order Supply Up to a 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.
25 visits per year.
Inpatient Coverage
Hospitalization 20% Coinsurance after deductible
Skilled Nursing Facility 20% Coinsurance after deductible.
Coverage is limited to 60 inpatient days / year.
Inpatient Mental Health 20% Coinsurance after deductible
Inpatient Substance Abuse 20% Coinsurance after deductible
Home Healthcare 20% Coinsurance after deductible.
Coverage is limited to 130 visits / 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 No charge for preventive and diagnostic services;
20% coinsurance for basic services;
50% coinsurance for major dental services. Deductible waived.
Vision Screening for Children No Charge.
Coverage is limited to 1 routine exam / year, deductible waived.
Eye Glasses for Children No Charge.
Coverage is limited to one frame and one pair (two lenses) / calendar year or contacts (in lieu of glasses), deductible waived.
Major Dental Coverage (Pediatric) 50% Coinsurance deductible waived
Additional Coverage
Chiropractic Coverage 20% Coinsurance after deductible, limit of 10 manipulations / year
Durable Medical Equipment 20% Coinsurance after deductible
Hospice 20% Coinsurance after deductible.
Coverage is limited to 14 respite days / lifetime.
Major Dental Coverage (Adult) 50% Coinsurance before deductible
Vision Coverage (Adult) 0% coinsurance before deductible. Coverage is limited to $150 for lenses/frames and one routine eye exam per calendar year
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $10,000 per insured per calendar year
Out-of-Network Annual Coinsurance 50% Coinsurance, subject to deductible
Out-of-Network Annual Out-of-Pocket Limit $12,500 per insured per calendar year
Additional Information
A.M. Best Rating A as of 07/02/2014
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.