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CoventryOne POS In-Network Benefit Summary* $2,000 and $2,500 Deductible Options (click here for out-of-network benefit summary)
Description of Benefits		$20 Copay Plan $2,000 Deductible	$30 Copay Plan $2,500 Deductible	$35 Copay Plan $2,500 Deductible	$45 Copay Plan $2,500 Deductible	HDHP (HSA) $1,250 Single Ded. $2,500 Fam. Ded.
Lifetime Maximum Per Member		$6,000,000	Unlimited	$7,000,000	Unlimited	$6,000,000
Annual Deductible Per Member (3 person maximum)		$2,000	$2,000	$2,500	$2,500	$1,250
Annual Out-of-Pocket Maximum (3 person family maximum)		$2,500 plus deductible per member	$3,000 plus deductible per member	$5,000 plus deductible per member	$5,000 plus deductible per member	Plan pays 100% after deductible
Office Visits - (PPO Physicians and Specialists-includeslab work only when performed in the physician's office)		$20/$55(also includes x-ray if done in Drs. Office)	$30/$60(also includes x-ray if done in Drs. Office)	$35 Family Dr.(unlimited vis) $50 Specialist (2 vis/yr then meet deductible)	$45 Family Dr.(unlimited vis) $75 Specialist (2 vis/yr then meet deductible)	Plan pays 100% after deductible
Convenience Care Clinic (ex. minute clinic or clinics set up within Walgreens, CVS, Kroger, etc)		$20	$30	$35	$45	Plan pays 100% after deductible
Preventive Care for Babies and Children (through age 5)		$20	$30	$35	$45	$20
Preventive Screenings for Adults (unlimited yearly max) Colonscopy will be paid at 70% after the yearly deductible is met.		$20	$30	$35	$45	$20
Mammograms Preventive and Diagnostic		Covered at 100% - no copay	Covered at 100% - no copay	Covered at 100% - no copay	Covered at 100% - no copay	Covered at 100% - no copay or deductible
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	Plan pays 100% 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	Plan pays 100% after deductible
Maternity		NOT COVERED	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	Plan pays 100% 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	Plan pays 100% 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	NOT COVERED
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	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	Plan pays 100% after deductible
Emergency Room Care - For Medical Emergency or Serious Accidental Injury- (Non emergency use of the emergency room is not a covered benefit)		$150 copay then 100% coverage (waived if admitted)	$250 copay then 100% coverage (waived if admitted)	$250 copay then 100% coverage (waived if admitted)	$500 copay then 100% coverage (waived if admitted)	Plan pays 100% after deductible
Urgent Care		$55 Copay	$75 Copay	$75 Copay	$75 Copay	Plan pays 100% after deductible
Ambulatory Surgical Center		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible
Ambulance Service		$150	$150	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible
Hospice		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% 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	Plan pays 100% 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	Plan pays 100% 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	Plan pays 100% 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	Plan pays 100% 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:	After a $500 deductible per person, you pay: (out of pocket max per person is $3000/yr)	After a $1,000 deductible per person, you pay:	After a $1,000 deductible per person, you pay: (out of pocket max per person is $3000/yr)	After deductible per person, you pay:
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	$10 copayment	$10 copayment	$10 copayment	$15 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$35 copayment	$35 copayment	$35 copayment	$40 copayment	$35 copayment
	Tier 3 (Non-Formulary Brand)	$50 copayment	$50 copayment	$50 copayment	$60 copayment	$50 copayment
	Tier 4 (self edministered injectables)	$100 copayment	Plan pays 70% after Rx. ded. is met	$100 copayment	Plan pays 70% after Rx. ded. is met	$100 copayment
Dental ( all care must be received from a DeltaCare HMO provider)		Various Copays	Not Included	Not Included	Not Included	Various Copays
Vision - one exam every 12 months (care must be received from an Avesis provider)		$15 Copay	$15 Copay	$15 Copay	$15 Copay	$15 Copay
Description of Benefits		$20 Copay Plan $2,000 Deductible	$30 Copay Plan $2,500 Deductible	$35 Copay Plan $2,500 Deductible	$45 Copay Plan $2,500 Deductible	HDHP (HSA) $1,250 Single Ded. $2,500 Fam. 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 9 Dunwoody Park Suite 136 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