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CoventryOne POS In-Network Benefit Summary* $4,000 to $5,750 Deductible Plan Options (click here for out-of-network benefit summary)
Description of Benefits		$30 Copay Plan $5,000 Deduct.	$35 Copay Plan $5,000 Deduct.	$45 Copay Plan $5,750 Deduct. $0 Prescription Deductible	$45 Copay Plan $5,750 Deduct. $1K Brand Rx Ded	Fusion 100%/50% $5,000 Deduct.	HDHP (HSA) $5,000 Single Ded. $10,500 Fam. Ded.
Lifetime Maximum Per Member		Unlimited	Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Annual Deductible Per Member (3 person maximum)		$5,000	$5,000	$5,750	$5,750	$5,000	$5,000
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	$0. Plan pays 100% after deductible is met	$5,000 plus deductible per member
Office Visits - (PCP Physicians and Specialists)		$30/$60 (includes X-ray and lab work only when performed and billed by the physician's office)	PCP-$35 unltd vis / Specialist-First 2 Visits: $50 3+$50 After Deduct.	PCP-$35 unltd vis / Specialist-First 2 Visits: $50 3+$50 After Deduct.	PCP-$35 unltd vis / Specialist-First 2 Visits: $50 3+$50 After Deduct.	First 6 Visits: $30 7+ Visits: $60 after Deduct.	Deductible
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	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	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	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	Plan pays 100% 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	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible	Deductible
Maternity		NOT COVERED	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	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	Deductible
Chiropractic Services (24 visits per year - Care must be received from ActivHealth Provider)		$10	$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	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	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 (waived if admitted)	$250 copay (waived if admitted)	$500 copay (waived if admitted)	$500 copay (waived if admitted)	$150 copay (waived if admitted)	Deductible
Urgent Care		$75 Copay	$75 Copay	$75 Copay	$75 Copay	$55 Copay	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	Deductible
Ambulance Service		$250	$250	$500	$500	$150	Deductible
Hospice		Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 70% with deductible waived	Plan pays 100% 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	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% 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	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% 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	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible	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	Deductible
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		After a $500 deductible per person, you pay:	After a $1,000 deductible per person, you pay:	$0 Deductible	After a $1,000 deductible per person, you pay:	After a $2000 deductible per person, you pay:	After deductible per person, you pay:
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.
P R E S C R I P T I O N	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	$10 copayment	$10 copayment	$15 copayment	$15 copayment	$10 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$35 copayment	$35 copayment	$40 copayment	$40 copayment	$35 copayment	$35 copayment
	Tier 3 (Non-Formulary Brand)	$50 copayment	$50 copayment	$60 copayment	$60 copayment	$50 copayment	$50 copayment
	Tier 4 (self edministered injectables)	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	$100 copayment
Dental ( all care must be received from a DeltaCare HMO provider)		No Coverage	No Coverage	No Coverage	No Coverage	No Coverage	No Coverage
Vision - one exam every 12 months (care must be received from an Avesis provider)		$15 Copay	$15 Copay	$15 Copay	$15 Copay	$15 Copay	$15 Copay
Description of Benefits		$30 Copay Plan $5,000 Deduct.	$35 Copay Plan $5,000 Deduct.	$45 Copay Plan $5,000 Deduct. $0 Prescription Deductible	$45 Copay Plan $5,000 Deduct. $1K Brand Rx Ded-NEW! Lower Cost Plans for 7-1 Click Here for Details	Fusion 100%/50% $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)

Insurance Now 5 Dunwoody Park South 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