Insurance Plan Summary
Company
Plan Name
SmartSense 5000 with Comprehensive RX
Plan Type
PPO
Primary Care Physician Required
No
Specialist Referrals Required
No
HSA Eligible
No
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
30% after deductible
Office Visit
Primary Doctor
$30 copay for first 3 visits per member per year (deductible waived); after 3 visits 30% coinsurance after deductible
Specialist
$30 copay for first 3 visits per member per year (deductible waived); after 3 visits 30% coinsurance after deductible
Periodic Health Exam
30% Coinsurance after deductible
Periodic OB-GYN Exam
30% Coinsurance after deductible
Well Baby Care
30% Coinsurance after deductible (through age 6)
Chiropractic
30% Coinsurance after deductible (plan pays up to $500 per year)
Mental Health
Not covered
Prescription Drugs
Generic
$15 Copay (or 40% Coinsurance, whichever is greater)
Brand
$15 Copay (or 40% Coinsurance, whichever is greater); 40% of negotiated fee for self-administered injectables, except insulin
Non-Formulary
50% Coinsurance after deductible
Separate Rx Deductible
Medical Plan Deductible Applies
Mail Order
Available
Outpatient Lab/X-Ray
30% Coinsurance after deductible
Emergency Room
30% Coinsurance after deductible (additional $100 copay for each visit, waived if admitted)
Outpatient Surgery
30% Coinsurance after deductible
Hospitalization
30% 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
More Details
Exclusions and Limitations
Exclusions and Limitations
Actions
Company
Plan Name
SmartSense 5000 with Comprehensive RX
Get live professional advice about this insurance plan
Get Live Advice
