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5000 100/0
Plan Summary
Plan Type PPO
Office Visit for Primary Doctor
Find Doctors 		This plan pays one $50 benefit for one doctor visit. Subsequent visits apply to deductible and coinsurance.
Office Visit for Specialist No Charge after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $5,000
Separate Prescription Drugs Deductible N/A
Coinsurance No Charge after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $5,000
Includes deductible
Lifetime Maximum $1 Million per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required N/A
Specialist Referrals Required N/A
Preventive Care Coverage
Periodic Health Exam No Charge after deductible
Periodic OB-GYN Exam Not covered
Well Baby Care Not covered
Emergency and Urgent Care
Emergency Room No Charge after deductible. Additional $250 ER deductible (waived if the Covered Person is directly admitted to the Hospital as an inpatient due to that Injury or Sickness)
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible N/A
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery No Charge after deductible
Outpatient Lab/X-Ray No Charge 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 No Charge 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 N/A
Labor & Delivery Hospital Stay N/A
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 Not covered
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 A- as of 09/05/2019
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

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.