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Plan Type Indemnity
Office Visit for Primary Doctor
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50% Coinsurance after deductible
Office Visit for Specialist 50% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $250
Separate Prescription Drugs Deductible Not Covered
Coinsurance 50% Coinsurance after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $2,500
Does not include deductible
Lifetime Maximum $250,000 per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Paid as out-of-network benefits 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam Not Covered
Periodic OB-GYN Exam Not Covered
Well Baby Care Not Covered
Emergency and Urgent Care
Emergency Room 50% Coinsurance after deductible
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible Not Covered
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery 50% Coinsurance after deductible
Outpatient Lab/X-Ray 50% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 50% Coinsurance after deductible
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Not Covered
Labor & Delivery Hospital Stay Not Covered
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage 50% Coinsurance after deductible, 5 Visits per plan term
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/Apd as of 11/21/2013
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.

Customer reviews

Important notices and disclaimers

  • 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.