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Coventry Open Access 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.

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 Adults 
 $20 Copay $20 Copay $20 Copay $20 Copay $20 Copay $20 Copay  
 
Preventative Care Children 
 $20 Copay $20 Copay $20 Copay $20 Copay $20 Copay $20 Copay  
 
Emergency Room 
 $150 Copay $150 Copay $150 Copay $150 Copay $150 Copay $150 Copay  
 
Perscription 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		  
 
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  
 
Rx Deductible 
 $100 $250 $250 $250 $500 $500  
 
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		  
 
Outpatient Surgery 
  
 
Outpatient Lab / X-Ray 
  
  
Maternity 
 Not covered Not covered Not covered Not covered Not covered Not covered  
 
Pre-Existing Conditions 
12 month waiting period  
 
Rate Guarantee 
    
 
First Year 
1 year 1 year 1 year 1 year 1 year 1 year  
Renewal Years 
              
   B++  B++  B++  B++  B++  B++  
 
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.
This is an outline of coverage only. Please see full plan brochure including exclusions and limitations before applying.


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