Insurance Plan Summary |
|
Company |
|
Plan Name |
Basic PPO 1000 |
Plan Type |
PPO |
Primary Care Physician Required |
No |
Specialist Referrals Required |
No |
HSA Eligible |
No |
Out-of-Network Coverage |
Yes |
In-Network Coverage |
|
Coinsurance |
20% after deductible |
Office Visit |
|
Primary Doctor |
Not Covered until out-of-pocket limit met; then covered 100% |
Specialist |
Not Covered until out-of-pocket limit met; then covered 100% |
Periodic Health Exam |
HealthyCheck Centers: $25 Copay for basic screenings or $75 Copay for premium screenings (ages 7 to adult), deductible waived |
Periodic OB-GYN Exam |
20% Coinsurance, deductible waived |
Well Baby Care |
Not Covered |
Chiropractic |
Not Covered |
Mental Health |
Plan pays $25 per visit after out-of-pocket is met, up to 20 visits per calendar year |
Prescription Drugs |
|
Generic |
Not Covered |
Brand |
Not Covered |
Non-Formulary |
Not Covered |
Separate Rx Deductible |
None |
Mail Order |
Not Available |
Outpatient Lab/X-Ray |
No Charge after out-of-pocket maximum is met |
Emergency Room |
$100 Copay (waived if admitted) Plus 20% Coinsurance after deductible |
Outpatient Surgery |
20% Coinsurance after deductible |
Hospitalization |
20% Coinsurance after deductible |
Maternity |
|
Pre & Postnatal Office Visit |
Not Covered |
Labor & Delivery Hospital Stay |
Not Covered |
Additional Information |
|
Will insurance company obtain and pay for medical records? |
Yes |
eSign (electronic signature)
|
Yes |
A.M. Best Rating |
A as of 11/06/2006 |
More Insurance Plan Details |
|
Exclusions and Limitations |
|
Actions |
|
Company |
|
Plan Name |
Basic PPO 1000 |
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