|
|
|
|
|
|
|
QHD
1250 |
QHD 3000
|
QHD
5000 |
|
|
|
In-Network Coverage |
|
|
|
|
|
Office
Visit1 |
|
|
|
|
|
Primary
Doctor |
Plan
pays 100%
after deductible |
Plan pays 100%
after deductible |
Plan pays 100%
after deductible |
|
|
Specialist |
Plan
pays 100%
after deductible |
Plan pays 100%
after deductible |
Plan pays 100%
after deductible |
|
|
Preventative Care
Adults |
$20
Copay |
$20 Copay |
$20
Copay |
|
|
Preventative Care
Children |
$20
Copay |
$20 Copay |
$20 Copay |
|
|
Emergency
Room |
Plan pays
100%
after deductible |
Plan pays
100%
after deductible |
Plan pays
100%
after deductible |
|
|
|
Perscription
Drugs |
|
|
|
|
|
|
Generic |
$10 Copay
after
deductible |
$10 Copay
after deductible |
$10 Copay
after deductible |
|
|
|
Brand |
$35 Copay
after
deductible |
$35 Copay
after deductible |
$35 Copay
after deductible |
|
|
|
Non-Formulary |
$50 Copay
after
deductible |
$50 Copay
after deductible |
$50 Copay
after deductible |
|
|
|
Rx
Deductible |
N/A |
N/A |
N/A |
|
| |
Calendar Year Max Rx
Benefit |
Unlimited |
Unlimited |
Unlimited |
|
|
|
Deductible |
$1,250 |
$3,000 |
$5,000 |
|
|
|
Coinsurance |
100% / 0% |
100% / 0% |
100% / 0% |
|
|
Coinsurance
Limit |
N/A |
N/A |
N/A |
|
|
Out-of-Pocket
Limit |
$1,250
|
$3,000 |
$5,000
|
|
|
deductible + coinsurance |
|
|
|
Lifetime
Maximum |
$6,000,000 |
$6,000,000 |
$6,000,000 |
|
|
Hospitalization |
Plan pays 100%
after
deductible |
Plan pays
100%
after deductible |
Plan pays 100%
after deductible |
|
|
|
Outpatient
Surgery |
|
|
|
Outpatient Lab /
X-Ray |
|
|
|
Maternity |
Not Covered |
Not Covered |
Not Covered |
|
| |
Pre-Existing Conditions
|
|
|
|
|
Rate Guarantee |
|
|
|
|
| |
|
1 year |
1 year |
1 year |
|
|
|
Renewal
Years |
|
|
|
|
| |
|
B++ |
B++ |
B++ |
|
| |
Price Stability
Rating |
B |
B |
B |
|
| |
|
1 Office Visit
Copays include charges for x-rays and labs when performed and billed
by the doctor's office.
|
This is
an outline of coverage only.
Please see full plan brochure
including exclusions and limitations before applying.
|
