CoventryOne Authorized Agent
  

CoventryOne POS In-Network Benefit Summary*
$2,500 and $2,750 Deductible Options
(click here for out-of-network benefit summary)

Description of Benefits

$30 Copay Plan
$2,500 Deductible

$35 Copay Plan
$2,500 Deductible

$45 Copay Plan
$2,500 Deductible
$0 Prescription Ded.

$45 Copay Plan-$1500 Ded. with $1000
Brand Prescription Ded.

 

Lifetime Maximum Per Member

Unlimited

Unlimited

Unlimited

Unlimited
Annual Deductible Per Member
(3 person maximum)

$2,000

$2,500

$2,500

$2,500
Annual Out-of-Pocket Maximum
(3 person family maximum)

$3,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member
Office Visits - (PCP Physicians and Specialists)

$30/$60(also includes
lab and x-ray if done in Drs. Office)

$35 Family Dr.(unlimited vis)
$50 Specialist (2 vis/yr
then meet deductible)-also includes lab if done in Drs. ofc

$45 Family Dr.(unlimited vis)
$75 Specialist (2 vis/yr
then meet deductible)

$45 Family Dr.(unlimited vis)
$75 Specialist (2 vis/yr
then meet deductible)
Convenience Care Clinic (ex. minute clinic or clinics set up within Walgreens, CVS, Kroger, etc)

$30

$35

$45

$45
Preventive Care for Babies and Children (through age 5)

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay
Preventive Screenings for Adults
(unlimited yearly max)
Colonscopy will be paid at 70% after the yearly deductible is met.

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay
Mammograms
Preventive and Diagnostic

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay

Covered at 100% - no copay
Professional Services
Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Inpatient Hospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Maternity

NOT COVERED

NOT COVERED

NOT COVERED

NOT COVERED
Outpatient Medical Care

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Short Term Therapies:
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
(no limit on # of visits)
Developmental Delay is not covered

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
 Chiropractic Services
(24 visits per year - Care must be received from specific in network vendors-call 770-396-9517)		  $10  $10  $10  $10
 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
Infusion Therapy/Chemotherapy

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Emergency Room Care -

For Medical Emergency or Serious Accidental Injury- (Non emergency use of the emergency
room is not a covered benefit)

$250 copay then 100% coverage (waived if admitted)

$250 copay then 100% coverage (waived if admitted)

$500 copay then 100% coverage (waived if admitted)

$500 copay then 100% coverage (waived if admitted)
 Urgent Care

$75 Copay

$75 Copay

$75 Copay

$75 Copay
Ambulatory Surgical Center

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Ambulance Service

$150

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Hospice

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Home Health Care -
Limited to 30 days, in and out of network combined

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Durable Medical Equipment, Prosthetics and Orthoses
limited to $2,500 annual max, all combined

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Skilled Nursing Facility
Limited to 30 days, in and out of network combined

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Transplants
(Unlimited Benefit)

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Prescription Drugs -
Retail Drugs - per prescription (up to a 30-day supply-mail order available)

After a $250 deductible per person, you pay:
(ded. only applies to brand name prescriptions)

After a $500 deductible per person, you pay:
(ded. only applies to brand name prescriptions)

$0 deductible per person, you pay:

After a $1,000 deductible per person, you pay:
(ded. only applies to brand name prescriptions)

 CoventryOne has an out of pocket maximum of $3000 that you will pay per person per year for your prescription medications - Once your out-of-pocket maximum is met, CoventryOne will pay your prescriptions for the remainder of the year.

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 Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)

$10 copayment
No Deductible Applies

$10 copayment
No Deductible Applies

$15 copayment
No Deductible Applies

$15 copayment
No Deductible Applies
Tier 2 (Formulary Brand)

$35 copayment
After Deductible is Met

$35 copayment
After Deductible is Met

$40 copayment
No Deductible Applies

$40 copayment
After Deductible is Met
Tier 3 (Non-Formulary Brand)

$50 copayment
After Deductible is Met

$50 copayment

$60 copayment

$60 copayment
Tier 4 (self edministered injectables)

$100 copayment
After Deductible is Met

70% cov'g after Rx. Ded.

70% cov'g

70% cov'g after Rx. Ded.
Dental ( all care must be received from a DeltaCare HMO provider)

Not Included

Not Included

Not Included

Not Included
Vision - one exam every 12 months (care must be received from an Avesis provider)

$15 Copay

$15 Copay

$15 Copay

$15 Copay

Description of Benefits

$30 Copay Plan
$2,500 Deductible

$35 Copay Plan
$2,500 Deductible

$45 Copay Plan
$2,500 Deductible
$0 Prescription Ded.

$45 Copay Plan
$2,500 Deductible
$1K Brand Rx Ded.

 

Waiting period for all undisclosed pre-existing conditions is at least one year from contract effective date.
*Refer to your individual certificate of coverage for complete benefit details
(As with all insurance providers, not disclosing known prexisting conditions could result in termination of your benefits)
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Insurance Now
5 Dunwoody Park
Suite 113
Atlanta, GA 30338

Call Holly, Chris or Bob at
(770) 396-9517
Outside of the Atlanta area,
call toll-free: 1-877-711-8376
fax: 770-396-4318
Email: holly@insurance-now.com