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Plan Type POS
Metal Level Bronze
Office Visit for Primary Doctor
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$15 Copay
Office Visit for Specialist First Visit: $75; 2+ Visits: $75 Copay + Deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $15 Copay
Annual Deductible Individual: $5,500
Separate Prescription Drugs Deductible Integrated Medical / Rx Deductible
Coinsurance 30% Coinsurance, subject to deductible
Retail Prescription Drugs Tier 1 - Preferred Generic Drugs: Preferred Pharmacy $15 / Non Preferred Pharmacy $20;
Tier 2- Preferred Brand Drugs: Preferred Pharmacy Deductible + $45 / Non Preferred Pharmacy Deductible + $55;
Tier 3 - Non Preferred Brand/Generic Drugs: Preferred Pharmacy Deductible + $75 / Non Preferred Pharmacy Deductible + $85;
Tier 4 - Preferred Specialty Drugs: Preferred Pharmacy Deductible + 30% Coinsurance;
Tier 5 - Non Preferred Specialty Drugs: Preferred Pharmacy Deductible + 40% Coinsurance
Annual Out-of-Pocket Limit Individual: $6,350
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 Emergency Care Only.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam $0 Copay
Periodic OB-GYN Exam $0 Copay
Well Baby Care $0 Copay
Emergency and Urgent Care
Emergency Room First Visit: $500 Copay; 2+ Visits: $500 Copay after deductible
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility $150 Copay
Prescription Drug Coverage
Retail Prescription Drugs Tier 1 - Preferred Generic Drugs: Preferred Pharmacy $15 / Non Preferred Pharmacy $20;
Tier 2- Preferred Brand Drugs: Preferred Pharmacy Deductible + $45 / Non Preferred Pharmacy Deductible + $55;
Tier 3 - Non Preferred Brand/Generic Drugs: Preferred Pharmacy Deductible + $75 / Non Preferred Pharmacy Deductible + $85;
Tier 4 - Preferred Specialty Drugs: Preferred Pharmacy Deductible + 30% Coinsurance;
Tier 5 - Non Preferred Specialty Drugs: Preferred Pharmacy Deductible + 40% Coinsurance
Separate Prescription Drugs Deductible Integrated Medical / Rx Deductible
Mail Order Prescription Drugs Tier 1 - Preferred Generic Drugs: $30;
Tier 2 - Preferred Brand Drugs: Deductible + $112.50;
Tier 3 - Non Preferred Brand/Generic Drugs: Deductible + $225
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery $250 Copay + 30% Coinsurance after Deductible
Outpatient Lab/X-Ray 30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) $250 Copay + 30% Coinsurance after Deductible
Outpatient Mental Health 30% Coinsurance after deductible; office visits will be paid at Specialist Visit Copay
Outpatient Substance Abuse 30% Coinsurance after deductible; office visits will be paid at Specialist Visit Copay
Outpatient Rehabilitation Services (PT, OT, ST) 30% Coinsurance after deductible
Inpatient Coverage
Hospitalization $500 Copay + 30% Coinsurance after Deductible
Skilled Nursing Facility 30% Coinsurance after deductible
Inpatient Mental Health $500 Copay + 30% Coinsurance after Deductible
Inpatient Substance Abuse $500 Copay + 30% Coinsurance after Deductible
Home Healthcare 20% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit $0 Copay
Labor & Delivery Hospital Stay $1,000 Copay + 30% Coinsurance after Deductible
Pediatric Services
Dental Checkup for Children $0 Copay
Vision Screening for Children One routine eye examination per year
Eye Glasses for Children One pair of standard eyeglass lenses or contact lenses per year; one frame per year
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage Not Covered
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 Yes
Out-of-Network Annual Deductible $6,400/$12,800
Out-of-Network Annual Coinsurance 50%
Out-of-Network Annual Out-of-Pocket Limit Unlimited
Additional Information
A.M. Best Rating A- as of 06/13/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View 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.

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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 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.