Georgia Health Insurance Plans From Coventry

CoventryOne Authorized Agent

CoventryOne POS In-Network Benefit Summary* $1500 Deductible Plan Options (click here for out-of-network benefit summary)
Description of Benefits		$30 Copay Plan $1,500 Deductible	$35 Copay Plan $1,500 Deductible	$45 Copay Plan -$1,500 Deductible $0 RX Ded.	$45 Copay Plan-$1500 Ded. w/ $1000 Brand Rx Ded. NEW! Lower Cost Plan for 7-1 Effective Date-Click Here

Lifetime Maximum Per Member		Unlimited	Unlimited	Unlimited	Unlimited
Annual Deductible Per Member (3 person maximum)		$1,500	$1,500	$1,500	$1,500
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
Office Visits -Physicians and Specialists)		$20/$55 (includes lab and xray when performed in physicians office)	$30/$60 (includes lab and xray when performed in physicians office)	$35/$50 (1st 2 spec. visits/year - $50 after 2 visits-pay deductible then $50-includes lab when drawn in physicians office)	$45/$75 (1st 2 spec. visits/year - $50 after 2 visits-pay deductible then $50)
Convienent Care Clinic (ex. minuteclinic, CVS med clinic, etc)		$20 Copay	$30 Copay	$35 Copay	$45 Copay
Preventive Care for Babies and Children		Covered at 100%	Covered at 100%	Covered at 100%	Covered at 100%
Preventive Screenings for Adults		Covered at 100%	Covered at 100%	Covered at 100%	Covered at 100%
Mammograms Preventive and Diagnostic		Covered at 100%	Covered at 100%	Covered at 100%	Covered at 100%
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 (Various # on visit limits-call for details) 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 ActivHealth Provider)		$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 (ER copays are waived if admitted) (Non emergency use of the emergency room is not a covered benefit)		$150 copay then 100% coverage	$250 copay then 100% coverage	$250 copay then 100% coverage	$250 copay then 100% coverage
Urgent Care		$55 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	$250	$250	$500
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
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.
P R E S C R I P T I O N	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 after Rx. Ded.	70% cov'g after Rx. Ded.
Dental ( all care must be received from a DeltaCare provider.		Various Copays	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
Description of Benefits		$30 Copay Plan $1,500 Deductible	$35 Copay Plan $1,500 Deductible	$45 Copay Plan $1,500 Deductible $0 Prescription Deductible	$45 Copay Plan $1,500 Deductible $1000 Brand Rx Deduct.

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