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  2008 POS Copay Plans (Point-of-Service)

Click here for a PDF of the POS Copay Plan. You can download, view, and print using Adobe Acrobat Reader that is free and can be downloaded from www.adobe.com.

IN-NETWORK OUT-OF-NETWORK
Coventry One Plans Office Visit Copay ER* Visit Copay Annual Deductible Individual/ Family Coinsurance After Deductible Annual OOP** Maximum Annual Deductible Coinsurance Annual OOP** Maximum In-Network Pharmacy Benefit All Plans
POS Copay $40 $200 $500 20% $1,500 $1,000 40% $3,000
500 Unlimited Individual Individual Individual Individual
Visits
$1,000 $3,000 $2,000 $6,000
Family Family Family Family
POS Copay $40 $200 $750 20% $1,750 $1,500 40% $3,500
750 Unlimited Individual Individual Individual Individual
Visits
$1,500 $3,500 $3,000 $7,000
Family Family Family Family $10 Tier One Copay
$35 Tier Two Copay $60 Tier Three Copay $100 Self-Administered Injectables Copay
POS Copay 1000 $40 Unlimited Visits $200 $1,000 Individual $2,000 Family 20% $2,000 Individual $4,000 Family $2,000 Individual $4,000 Family 40% $4,000 Individual $8,000 Family
POS Copay $40 $200 $1,500 20% $2,500 $3,000 40% $5,000
1500 Unlimited Individual Individual Individual Individual
Visits
$3,000 $5,000 $6,000 $10,000
Family Family Family Family
POS Copay $40 $200 $2,500 20% $3,500 $5,000 40% $7,000
2500 Unlimited Individual Individual Individual Individual
Visits
$5,000 $7,000 $10,000 $14,000
Family Family Family Family
POS Copay $40 $200 $5,000 20% $6,000 $10,000 40% $12,000
5000 Unlimited Individual Individual Individual Individual
Visits
$10,000 $12,000 $20,000 $24,000
Family Family Family Family

  • Annual Deductible and Out-of-Pocket Maximum coincide with your contract year.
  • Out-of-Pocket Maximum includes Medical Copays (not Rx copays), Deductible and Coinsurance.
  • Lab and x-rays are covered in full In-Network.
  • Family Deductible and Out-of-Pocket = two times the Individual Deductible.
  • Coinsurance reflects member responsibility.
Payment for covered services received Out-of-Network are based upon CoventryOne's™ Out-of-Network reimbursement rates. In addition to your Coinsurance, you are responsible for paying Out-of-Network providers the difference between the Out-of-Network rate and their actual charges for non-emergency services.

* ER = Emergency Room ** Primary Care Physician ***OOP = Out-of-Pocket
2008 POS Copay Plans Schedule of Benefits

Benefit In-Network Payment Out-of-Network Payment Limitation
Lifetime Maximum Benefit $5,000,000 per person $5,000,000 per person In & Out-of-Network combined.
Physician Office Visit (no referrals required) $40 Copay – Unlimited visits Deductible & Co-insurance.
Routine Eye Exam (Through Avesis Provider) $15 Copay Not a covered benefit. One eye exam per year
Routine Mammogram, Lab & X-ray No Copay necessary. Covered in full. Deductible & Co-insurance.
Urgent Care Facility or Urgent Care at a Physician’s Office $40 Copay $40 Copay
Hospital Emergency Room Visit $200 Copay (Waived if admitted) $200 Copay (Waived if admitted)
Chiropractic Care Visit $40 Copay Deductible & Co-insurance. After initial evaluation, treatment plan must be approved by Coventry Health Care to authorize additional visits.
Inpatient & Outpatient Hospital and Professional Services, Home Health Care, Hospice Care, Ambulance Services, Outpatient Facility Services, and Diagnostic Imaging Deductible & Co-insurance. Deductible & Co-insurance.
Short Term Rehabilitative Therapy, Durable Medical Equipment, and Skilled Nursing Facility Services Deductible & Co-insurance. Deductible & Co-insurance. Short Term Rehabilitative Therapy is limited to 20 visits per contract year per episode. Durable Medical Equipment limited to an maximum benefit of $5,000 per contract year. Skilled Nursing Facility care is limited to 30 inpatient days per contract year.
Maternity Services Not a covered benefit except for complications. Not a covered benefit.
Inpatient & Outpatient Mental Health Services Not a covered benefit. Not a covered benefit.
Inpatient & Outpatient Alcohol and Drug Abuse Services Not a covered benefit. Not a covered benefit.
Infertility, Custodial Care, Dental Services Not a covered benefit. Not a covered benefit.
Rx Outpatient Benefit Retail Purchase Mail Order (90 day supply) $10 Tier One Copay $35 Tier Two Copay $60 Tier Three Copay $100 Self Administered Injectables Copay $20 Tier One Copay $70 Tier Two Copay $120 Tier Three Copay $200 Self Administered Injectables Copay Not a covered benefit Not a covered benefit

Payment for covered services received out of network are based upon Coventry Health Care's out of network reimbursement rates. In addition to your copay or coinsurance , you are responsible for the difference between our out of network rate and the actual charge for non emergency services. This summary is designed as a partial description of the coverage being offered and in no way details all benefits, limitations, exclusions, terms, or conditions. Complete details of the exact terms, conditions, and scope of coverage including all limitations and exclusions are governed by the Coventry Health Care Individual Membership Agreement.

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