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  2008 POS Copay Value Plan

Click here for a PDF of the POS Copay Value 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 Office Visit or Annual Coinsurance Annual Annual Annual In-Network
One Emergency Deductible After OOP*** Deductible Coinsurance OOP*** Pharmacy
Plans Room Visit Individual / Family Deductible Maximum Indiv / Family Individual / Family Maximum Indiv / Family Benefit All Plans
(Choose one)
POS Copay $45 PCP** $500 30% $3,500 $1,000 50% $7,000
Value 500 $65 Specialist Individual Individual Individual Individual Option A
Unlimited Visits $10 Tier 1 Copay
$75 Urgent Care $1,000 $7,000 $2,000 $14,000 (no deductible)
$250 ER* copay Family Family Family Family $500 Rx
Deductible on Tier 2 – Tier 4
POS Copay $45 PCP** $1,000 30% $4,000 $2,000 50% $8,000
Value 1000 $65 Specialist Unlimited Visits Individual Individual Individual Individual (Family = 2x ) $35 Tier 2 Copay $60 Tier 3 Copay
$75 Urgent Care $250 ER* copay $2,000 Family $8,000 Family $4,000 Family $16,000 Family $100 Self-Administered Injectables
POS Copay $45 PCP** $2,500 30% $5,500 $5,000 50% $11,000 Copay
Value 2500 $65 Specialist Individual Individual Individual Individual
Unlimited Visits Or
$75 Urgent Care $5,000 $11,000 $10,000 Family $22,000
$250 ER* copay Family Family Family Option B
POS Copay Value 5000 $45 PCP** $65 Specialist $5,000 Individual 30% $8,000 Individual $10,000 Individual 50% $16,000 Individual $10 Tier 1 Copay (no deductible)
Unlimited Visits $1,000 Rx
$75 Urgent Care $250 ER* copay $10,000 Family $16,000 Family $20,000 Family $32,000 Family Deductible on Tier 2 – Tier 4 (Family = 2x )
$35 Tier 2 Copay $60 Tier 3 Copay $100 Self-Administered
POS Copay Value 7500 $45 PCP** $65 Specialist Unlimited Visits $7,500 Individual 30% $10,500 Individual $15,000 Individual 50% $21,000 Individual
$75 Urgent Care $250 ER* copay $15,000 Family $21,000 Family $30,000 Family $42,000 Family Injectables Copay

  • 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 Value Plans

Benefit In-Network Payment Out-of-Network Payment Limitation
Lifetime Maximum Benefit per person $5,000,000 $5,000,000 In & Out-of-Network combined.
Physician Office Visit or Urgent Care (no referrals required) $45 PCP copay / $65 Specialist copay $75 Urgent Care copay Unlimited visits Deductible & Co-insurance. No limit on number of office visits.
Routine Eye Exam (Through Avesis Provider) $15 Copay – one per year Not a covered benefit.
Routine Mammogram, Lab & X-ray No copay necessary. Covered in full. Deductible & Co-insurance.
Hospital Emergency Room Visit $250 Copay (Waived if admitted) $250 Copay (Waived if admitted)
Chiropractic Care Visit $65 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 a 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 (Option A) Retail Purchase Mail Order (90 day supply) $10 Tier 1 Copay (no deductible) $500 Rx Deductible on Tier 2 – Tier 4 $35 Tier 2 Copay $60 Tier 3 Copay $100 Tier 4 Self-Administered Injectables Copay $20 Tier 1 Copay (no deductible) $500 Rx Deductible on Tier 2 – Tier 4 $70 Tier 2 Copay $120Tier 3 Copay Self-Administered Injectables not available via mail order Not a covered benefit. Not a covered benefit. Rx deductible for a family is 2x the individual deductible
Rx Outpatient Benefit (Option B) Retail Purchase Mail Order (90-day supply) $10 Tier 1 Copay (no deductible) $1000 Rx Deductible on Tier 2 – Tier 4 $35 Tier 2 Copay $60 Tier 3 Copay $100 Tier 4 Self-Administered Injectables Copay $20 Tier 1 Copay (no deductible) $1000 Rx Deductible on Tier 2 – Tier 4 $70 Tier 2 Copay $120Tier 3 Copay Self-Administered Injectables not available via mail order Not a covered benefit. Not a covered benefit. Rx deductible for a family is 2x the individual deductible

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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