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Plan Type HMO
Metal Level Platinum
Office Visit for Primary Doctor
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$20 Copay
Office Visit for Specialist $40 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $20 Copay
Annual Deductible None
Separate Prescription Drugs Deductible None
Coinsurance 10% Coinsurance, deductible waived
Retail Prescription Drugs Tier 1: $5 Copay; Tier 2: $15 Copay; Tier 3: $25 Copay
Annual Out-of-Pocket Limit Individual: $4,000
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Emergency Care Only.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
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 $150 Copay
Emergency Ambulance Services $150 Copay
Urgent Care Facility $40 Copay
Prescription Drug Coverage
Retail Prescription Drugs Tier 1: $5 Copay; Tier 2: $15 Copay; Tier 3: $25 Copay
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs Tier 1: $10 Copay; Tier 2: $30 Copay; Tier 3: $50 Copay
Mail Order Supply 90 Day supply
Outpatient Coverage
Outpatient Surgery $250 Copay
Outpatient Lab/X-Ray $20 Copay - lab $40 Copay - x-ray
Imaging (CT and PET scans, MRIs) $150 Copay
Outpatient Mental Health $20 Copay
Outpatient Substance Abuse $20 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $20 Copay
Inpatient Coverage
Hospitalization $250 Copay per day up to 5 days
Skilled Nursing Facility $150 Copay per day up to 5 days
Inpatient Mental Health $250 Copay per day up to 5 days
Inpatient Substance Abuse $250 Copay per day up to 5 days
Home Healthcare $20 Copay (Maximum stay 100 visits)
Maternity Coverage
Pre & Postnatal Office Visit No charge - prenatal $20 Copay - postnatal
Labor & Delivery Hospital Stay No charge - labor & delivery $250 Copay per day up to 5 days - inpatient hospital
Pediatric Services
Dental Checkup for Children No charge
Vision Screening for Children No charge
Eye Glasses for Children No charge
Major Dental Coverage (Pediatric) No charge
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 10% Coinsurance
Hospice No charge
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
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 B++ as of 04/06/2016
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.

Customer reviews

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.
  • Drug Savings amounts shown are only estimates — your costs and savings can differ. Check your plan information for accuracy. See details.