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CoventryOne POS In-Network Benefit Summary* $4,000 and $5,000 Deductible Plan Options (click here for out-of-network benefit summary)
Description of Benefits		$20 Copay Plan $4,000 Deduct.	$20 Copay Plan $5,000 Deduct.	Fusion 100%/50% $5,000 Deduct.	$35 Copay Plan $5,000 Deduct.	HDHP (HSA) $5,000 Single Ded. $10,500 Fam. Ded.
Lifetime Maximum Per Member		$6,000,000	$6,000,000	$6,000,000	$6,000,000	$6,000,000
Annual Deductible Per Member (3 person maximum)		$4,000	$5,000	$5,000	$5,000	$5,000
Annual Out-of-Pocket Maximum (3 person family maximum)		$2,500 plus deductible per member	$2,500 plus deductible per member	$0. Plan pays 100% after deductible is met	$5,000 plus deductible per member	$5,000 plus deductible per member
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		$20/$55	$20/$55	First 6 Visits: $30 7+ Visits: $60 after Deduct.	First 2 Visits: $50 3+ : $50 After Deduct.	Deductible
Preventive Care for Babies and Children (through age 5)		$20	$20	As Noted Above	$35	$20
Preventive Screenings for Adults (unlimited yearly max) Colonscopy will be paid at 70% after the yearly deductible is met.		$20	$20	As Noted Above	$35	$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
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	Deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	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	100%	Plan pays 70% after deductible	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	100%	Plan pays 70% after deductible	Deductible
Chiropractic Services (24 visits per year - Care must be received from ActivHealth Provider)		$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	100%	Plan pays 70% after deductible	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	$150 copay then 100% coverage	$150 copay then 100% coverage	$250 copay then 100% coverage	Deductible
Urgent Care		$55 Copay	$55 Copay	$55 Copay	$75 Copay	Deductible
Ambulatory Surgical Center		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	Deductible
Ambulance Service		$150	$150	$150	70%	Deductible
Hospice		Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	100%	Plan pays 70% with deductible waived	Deductible
Home Health Care - Limited to 30 days, in and out of network combined		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	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	100%	Plan pays 70% after deductible	Deductible
Skilled Nursing Facility Limited to 30 days, in and out of network combined		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	Deductible
Transplants (Unlimited Benefit)		Plan pays 70% after deductible	Plan pays 70% after deductible	100%	Plan pays 70% after deductible	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:	After a $2000 deductible per person, you pay:	After a $1,000 deductible per person, you pay:	After deductible per person, you pay:
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	$10 copayment	$10 copayment	$10 copayment	$10 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$35 copayment	$35 copayment	$35 copayment	$35 copayment	$35 copayment
	Tier 3 (Non-Formulary Brand)	$50 copayment	$50 copayment	$50 copayment	$50 copayment	$50 copayment
	Tier 4 (self edministered injectables)	$100 copayment	$100 copayment	70%	70% copayment	$100 copayment
Dental ( all care must be received from a DeltaCare HMO provider)		Various Copays	Various Copays	Various Copays	Various Copays	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 $4,000 Deduct.	$20 Copay Plan $5,000 Deduct.	Fusion 100%/50% $5,000 Deduct.	$35 Copay Plan $5,000 Deduct.	HDHP (HSA) $5,000 Single Ded. $10,500 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)
Click here to apply online! Click here to have an enrollment kit mailed or e-mailed to you (be sure to specify which plan you're interested in)
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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