CoventryOne Authorized Agent
  

CoventryOne POS In-Network Benefit Summary*
$45 Copay Plans

Description of Benefits

$45 Copay Plan
$1,750 Deductible

$45 Copay Plan
$2,750 Deductible

$45 Copay Plan
$3,750 Deductible

$45 Copay Plan
$5,750 Deductible

 
Lifetime Maximum Per Member

Unlimited

Unlimited

Unlimited

Unlimited
Benefit Year Deductible Per Member
(3 person maximum per family)

$5,750

$5,750

$5,750

$5,750
Benefit Year Out-of-Pocket Maximum
(3 person family maximum)

$5,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member
Office Visits - (PCP Physicians and Specialists)

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible
Preventive Care for Babies and Children  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)- NOTE: Colonscopy will be paid at 70% after the yearly deductible is met however Colon Screenings are covered at 100%		  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
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-24 visit limit/yr
Cardiac and Pulmonary Rehabilitation-
30 visits; Speech-24 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
Chiropractic Services - (6 visits per year - Care must be received from ActivHealth Provider) Plan Pays Up to $25/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/yr)
 Mental Health- Available only by purchase of an additional rider
(rider gives 48 O/P Vis & 30 I/P days per yr.)		 Optional rider available for additional $43/month Optional rider available for additional $43/month Optional rider available for additional $43/month Optional rider available for additional $43/month
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

$500 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)
Convenience Care Clinic

$45

$45

$45

$45
 Urgent Care Facility Services

$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
Ambulance Service

$500 Copay

$500 Copay

$500 Copay

$500 Copay
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
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)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)
P
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N		 Tier 1 (Generic Drugs)
(AVAILABLE WITHOUT MEETING
ANY DEDUCTIBLE)

$15 copayment

$15 copayment

$15 copayment

$15 copayment
Tier 2 (Formulary Brand)

$40 copayment

$40 copayment

$40 copayment

$40 copayment
Tier 3 (Non-Formulary Brand)

$60 copayment

$60 copayment

$60 copayment

$60 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

CoventryOne has an out of pocket maximum of $3000 that you will pay per person per year for your prescription medications at the most - Once your out-of-pocket maximum is met, CoventryOne will pay your prescriptions at 100% for the remainder of the year.
Dental

Optional Rider
Click Here for Detailed Summary

Optional Rider
Click Here for Detailed Summary

Optional Rider
Click Here for Detailed Summary

Optional Rider
Click Here for Detailed Summary
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

$45 Copay Plan
$1,750 Deductible

$45 Copay Plan
$2,750 Deductible

$45 Copay Plan
$3,750 Deductible

$45 Copay Plan
$5,750 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