CoventryOne Authorized Agent
  

CoventryOne POS Out-of-Network Benefit Summary*
$2,000 and $2,500 Deductible Options
(click here for in-network benefit summary)

Description of Benefits
(Out of Network Benefits)

$20 Copay Plan
$2,000 Deductible

$35 Copay Plan
$2,500 Deductible

HDHP (HSA)
$1,250 Single Ded.
$2,500 Fam. Ded.

 

Lifetime Maximum Per Member

$6,000,000

$7,000,000

$6,000,000
Annual Deductible Per Member
(3 person maximum)

$4,000

$5,000

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

$0

None

$2,500
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)

60%/60%

50% / 50%

405
Preventive Care for Babies and Children (through age 5)

NOT COVERED

50%

NOT COVERED
Preventive Screenings for Adults
(unlimited yearly max)
Colonscopy will be paid at 70% after the yearly deductible is met.

NOT COVERED

50%

NOT COVERED
Mammograms
Preventive and Diagnostic

60%

50%
 NOT COVERED
Professional Services
Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.

60%

50%

40%
Inpatient Hospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants

60%

50%

40%
Maternity

NOT COVERED

NOT COVERED

NOT COVERED
Outpatient Medical Care

60%

Pl50%

40%
Short Term Therapies:
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
(no limit on # of visits)
Developmental Delay is not covered

P60%

50%

40%
 Chiropractic Services
(24 visits per year - Care must be received from ActivHealth Provider)		 NOT COVERED NOT COVERED 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 
Infusion Therapy/Chemotherapy

60%

50%

40%

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 $250 copay then 100% coverage

Deductible
 Urgent Care

$55 Copay

$75 Copay

Deductible
Ambulatory Surgical Center

60%

50%

Deductible
Ambulance Service

$150

50%

Deductible
Hospice

60%

50%

40%
Home Health Care -
Limited to 30 days, in and out of network combined

60%

50%

40%
Durable Medical Equipment, Prosthetics and Orthoses
limited to $2,500 annual max, all combined

NOT COVERED

50%

Deductible
Skilled Nursing Facility
Limited to 30 days, in and out of network combined

60%

50%

40%
Transplants
(Unlimited Benefit)

NOT COVERED

NOT COVERED

Deductible
Prescription Drugs -
Retail Drugs - per prescription (up to a 30-day supply-mail order available)

Participating Pharmacies only

Participating Pharmacies only

After deductible per person, you pay:
Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)

Participating Pharmacies only

Participating Pharmacies only

Participating Pharmacies only
Tier 2 (Formulary Brand)

Participating Pharmacies only

Participating Pharmacies only

Participating Pharmacies only
Tier 3 (Non-Formulary Brand)

Participating Pharmacies only

Participating Pharmacies only

Participating Pharmacies only
Tier 4 (self edministered injectables)

Participating Pharmacies only

$100 copayment

Participating Pharmacies only
Dental ( all care must be received from a DeltaCare HMO provider)

DeltaCare providers only

DeltaCare providers only

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

Avesis Providers only

Avesis Providers Only

NOT COVERED

Description of Benefits

$20 Copay Plan
$2,000 Deductible

$35 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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Outside of the Atlanta area,
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