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CoventryOne POS In-Network Benefit Summary

$500 and $1000 Deductible Plan Options


Descriptionof Benefits	$20Copay Plan $500 Deductible	$20Copay Plan $1,000 Deductible	$35Copay Plan $1,000 Deductible	HDHP(HSA) $1,250 Single Ded. $2,500 Fam. Ded.
OfficeVisits - (PPOPhysicians and Specialists-includes X-ray and lab work onlywhen performed and billed by the physician's office)	$20/$55	$20/$55	$35/$50	Deductible
LifetimeMaximum Per Member	$6,000,000	$6,000,000	$7,000,000	$6,000,000
AnnualDeductible Per Member (3person maximum)	$500	$1,000	$1,000	$1,250
AnnualOut-of-Pocket Maximum (3person family maximum)	$2,500plus deductible per member	$2,500plus deductible per member	$5,000plus deductible per member	$1,250plus deductible per member
PreventiveCare for Babies and Children (throughage 5)	$20	$20	$35	$20
PreventiveScreenings for Adults (unlimited yearly max) Colonscopywill be paid at 70% after the yearly deductible is met.	$20	$20	$35	$20
Mammograms Preventive and Diagnostic	Coveredat 100% - no copay	Coveredat 100% - no copay	Coveredat 100% - no copay	Coveredat 100% - no copay
ProfessionalServices Including surgery, anesthesia, in-hospital physician care, diagnosticX-ray and lab.	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
InpatientHospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
Maternity	NOTCOVERED	NOTCOVERED	NOTCOVERED	NOTCOVERED
OutpatientMedical Care	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
ShortTerm Therapies: Physical/Occupational/Speech Respiratory Therapy, Cardiac and Pulmonary Rehabilitation (nolimit on # of visits) Developmental Delay is not covered	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
Chiropractic Services (24 visits per year - Care must be received from ActivHealthProvider)	$10	$10	$10	NOT COVERED
Mental Health- Available only by purchase of an additional rider (rider gives 48 O/P Vis & 30 I/P days per yr.)	Available only by purchasing a Rider	Available only by purchasing a Rider	Available only by purchasing a Rider	Available only by purchasing a Rider
InfusionTherapy/Chemotherapy	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
EmergencyRoom Care - ForMedical Emergency or Serious Accidental Injury (Non emergency use of the emergency room is not a covered benefit)	$150 copay then 100% coverage	$150 copay then 100% coverage	$250 copay then 100% coverage	Deductible
UrgentCare	$55Copay	$55Copay	$75Copay	Deductible
AmbulatorySurgical Center	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
AmbulanceService	$150	$150	70%	Deductible
Hospice	Planpays 70% with deductible waived	Planpays 70% with deductible waived	Planpays 70% with deductible waived	Deductible
Home HealthCare - Limited to 30 days, in and out of network combined	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
DurableMedical Equipment, Prosthetics and Orthoses limitedto $2,500 annual max, all combined	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
SkilledNursing Facility Limited to 30 days, in and out of network combined	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
Transplants (Unlimited Benefit)	Planpays 70% after deductible	Planpays 70% after deductible	Planpays 70% after deductible	Deductible
PrescriptionDrugs - Retail Drugs - per prescription (up to a 30-day supply-mail orderavailable)	After a $100 deductible per person, you pay:	After a $250 deductible per person, you pay:	After a $1,000 deductible per person, you pay:	After deductible per person, you pay:
Tier 1(Generic Drugs) (AVAILABLEWITHOUT MEETING ANY DEDUCTIBLE)	$10copayment	$10copayment	$10copayment	$10copayment
Tier 2(Formulary Brand)	$35copayment	$35copayment	$35copayment	$35copayment
Tier 3(Non-Formulary Brand)	$50copayment	$50copayment	$50copayment	$50copayment
Tier 4(self edministered injectables)	$100copayment	$100copayment	$100copayment	$100copayment
Dental ( all care must be received from a DeltaCare provider.	VariousCopays	VariousCopays	VariousCopays	VariousCopays
Vision - one exam every 12 months (care must bereceived from an Avesis provider)	$15Copay	$15Copay	$15Copay	$15Copay
Descriptionof Benefits	$20Copay Plan $500 Deductible	$20Copay Plan $1,000 Deductible	$35Copay Plan $1,000 Deductible	HDHP(HSA) $1,250 Single Ded. $2,500 Fam. Ded.