Georgia Health Insurance Plans From Coventry

CoventryOne Authorized Agent

CoventryOne POS In-Network Benefit Summary* $35 Copay Plans
Description of Benefits		$35 Copay Plan $1,000 Deductible	$35 Copay Plan $2,500 Deductible	$35 Copay Plan $5,000 Deductible	$35 Copay Plan $7,500 Deductible	$35 Copay Plan $10,000 Deductible

Lifetime Maximum Per Member		Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Annual Deductible Per Member (3 person maximum)		$1,000	$2,500	$5,000	$7,500	$10,000
Annual Out-of-Pocket Maximum (3 person family maximum)		Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		$35 Family Dr.(unlimited vis) $50 Specialist (2 vis/yr then meet deductible)	$35 Family Dr.(unlimited vis) $50 Specialist (2 vis/yr then meet deductible)	$35 Family Dr.(unlimited vis) $50 Specialist (2 vis/yr then meet deductible)	$35 Family Dr.(unlimited vis) Specialist (Pay deductible then $50/visit)	$35 Family Dr.(unlimited vis) Specialist (Pay deductible then $50/visit)
Preventive Care for Babies and Children (through age 5)		$0	$0	$0	$0	$0
Preventive Screenings for Adults (unlimited yearly max)		$0	$0	$0	$0	$0
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	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	Plan pays 70% 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 70% 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 70% after deductible
Chiropractic Services (12 visits per year - Care must be received from ActivHealth Provider)		$10	$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	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 70% after 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 then 100% coverage	$250 copay then 100% coverage	$250 copay then 100% coverage	$500 copay then 100% coverage	$500 copay then 100% coverage
Urgent Care		$75 Copay	$75 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	Plan pays 70% after deductible
Ambulance Service		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after 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 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	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	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	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	Plan pays 70% after deductible
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		After a $1,000 deductible per person, you pay:	After a $1,000 deductible per person, you pay:	After a $1,000 deductible per person, you pay:	After a $2,000 deductible per person, you pay:	After a $2,000 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	$100 copayment	$100 copayment	$100 copayment
Description of Benefits		$35 Copay Plan $1,000 Deductible	$35 Copay Plan $2,500 Deductible	$35 Copay Plan $5,000 Deductible	$35 Copay Plan $7,500 Deductible	$35 Copay Plan $10,000 Deductible

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