Copay Select 80 - 1000

Details at a Glance

• Plan Type
• Network
• Office Visit for Primary Doctor
• History and Exam: $35 Copay
• Office Visit for Specialist
• History and Exam: $35 Copay
• Coinsurance
• 20% after deductible
• Separate Prescription Drugs Deductible
• $100 Individual
  applies to
  Brand, Non-Formulary
• Prescription Drugs
• Generic: $15 Copay (Maximum $3,000 per covered person, per calendar year)
• Brand: $30 Copay (Maximum $3,000 per covered person, per calendar year)
• Non-Formulary: $60 Copay (Maximum $3,000 per covered person, per calendar year)
• 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
• History and Exam: $35 Copay ($300 annual max)
• Periodic OB-GYN Exam
• Mammogram, Pap Smear, PSA Testing: 20% Coinsurance
• Well Baby Care
• Child Immunizations ($300 annual max, ages 0-18) -- Vaccine: 20% Coinsurance

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay (Maximum $3,000 per covered person, per calendar year)
• Brand Prescription Drugs
• $30 Copay (Maximum $3,000 per covered person, per calendar year)
• Non-Formulary Prescription Drugs Coverage
• $60 Copay (Maximum $3,000 per covered person, per calendar year)
• Mail Order for Prescription Drugs
• Not Available
• Separate Prescription Drugs Deductible
• $100 Individual
  applies to
  Brand, Non-Formulary

Hospital Services Coverage

• Emergency Room
• Illness: 20% Coinsurance after deductible, additional $100 Copay per visit if not admitted; Injury: 20% Coinsurance after deductible
• Outpatient Lab/X-Ray
• 20% Coinsurance after deductible
• Outpatient Surgery
• 20% Coinsurance after deductible
• Hospitalization
• 20% Coinsurance after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not Covered
• Labor & Delivery Hospital Stay
• Not Covered

Additional Coverage

• Chiropractic Coverage
• 20% Coinsurance after deductible (limited to $2,000 of covered expenses per calendar year)
• Mental Health Coverage
• 20% Coinsurance after deductible, $50 Max. Benefit Per Visit, $3,000 Max. Benefit for lifetime

Additional Information

• A.M. Best Rating
• A as of 06/15/2009
• 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

Action

• Get live professional advice about this insurance plan
• Get Live Advice