| |
|
Coventry Copay POS Benefit Summary In-Network |
Copays are a first dollar Benefit and are not subject to the Deductible;
all other Benefits are subject to the Deductible unless stated otherwise. |
| All Benefits & Deductibles are per person, per plan year, unless stated otherwise.Out of network benefits will be less
|
| Benefits at a Glance |
|
|
|
|
|
| |
|
Plan 500 |
Plan 1000 |
Plan 2000 |
Plan 3000 |
Plan 5000 |
Plan 10000 |
|
|
In-Network Coverage |
|
|
|
|
|
|
|
|
Office Visit1 |
|
|
|
|
|
|
|
|
Primary Doctor |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
|
|
Specialist |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
|
|
Preventative Care |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
$20 Copay |
|
|
Emergency Care |
|
|
|
|
|
|
|
| |
Emergency Room |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
|
| |
Urgent Care |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
$55 Copay |
|
|
Prescription Drugs |
|
|
|
|
|
|
|
|
Generic |
No Deductible
$10 Copay |
No Deductible
$10 Copay |
No Deductible
$10 Copay |
No Deductible
$10 Copay |
No Deductible
$10 Copay |
No Deductible
$10 Copay |
|
| |
Rx Deductible |
$100 |
$250 |
$250 |
$250 |
$500 |
$500 |
|
|
Brand |
$35 Copay |
$35 Copay |
$35 Copay |
$35 Copay |
$35 Copay |
$35 Copay |
|
|
Non-Formulary |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
|
| |
Calendar Year Max Rx Benefit |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
|
|
Deductible |
$500 |
$1,000 |
$2,000 |
$3,000 |
$5,000 |
$10,000 |
|
|
Coinsurance |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
|
|
Coinsurance Limit |
$2,500 |
$2,500 |
$2,500 |
$2,500 |
$2,500 |
$2,500 |
|
|
Out-of-Pocket Limit |
$3,000
|
$3,500
|
$4,500 |
$5,500
|
$7,500 |
$12,500
|
|
|
deductible + coinsurance |
|
|
Lifetime Maximum |
$6,000,000 |
$6,000,000 |
$6,000,000 |
$6,000,000 |
$6,000,000 |
$6,000,000 |
|
| |
Hospitalization |
30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
30% Coinsurance
after deductible
|
30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
|
|
Surgery |
|
|
Lab / X-Ray |
|
|
Maternity |
Not covered |
Not covered |
Not covered |
Not covered |
Not covered |
Not covered |
|
| |
|
Included |
Included |
Included |
Included |
Included |
Included |
|
| |
Pre-Existing Conditions2 |
No waiting period when condition is disclosed on application. |
|
|
Rate Guarantee |
|
|
|
|
|
|
|
| |
|
1 year |
1 year |
1 year |
1 year |
1 year |
1 year |
|
|
Renewal Years |
|
|
|
|
|
|
|
| |
|
A- |
A- |
A- |
A- |
A- |
A- |
|
| |
Price Stability Rating |
B |
B |
B |
B |
B |
B |
|
| |
1 Office Visit Copays include charges for x-rays and labs when performed and billed by the doctor's office.
2
A pre-existing condition is a condition for which advice, diagnosis, care, treatement, or prescribed drug was recommended or recieved within
the 12 month period prior to your effective date of coverage.
All plans are subject to a 12 month waiting period for pre-existing conditions except when a condition is disclosed on the application at the
time
of medical underwriting and the policy is approved.
All Benefits shown are for services at In-Network providers. Out of Network Benefits will be less. Questions, call 404-575-1960. |
This is an outline of coverage only.
Please see full plan brochure including exclusions and limitations before applying. |
|
|
