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CoventryOne POS Out-of-Network Benefit Summary* (click here for in-network benefit summary)
Description of Benefits		$500	$1,000	$2,000	$3,000	$5,000	$10,000
Lifetime Maximum Per Member		$6,000,000	$6,000,000	$6,000,000	$6,000,000	$6,000,000	$6,000,000
Annual Deductible Per Member (3 person maximum)		$1,000	$2,000	$4,000	$6,000	$10,000	$20,000
Annual Out-of-Pocket Maximum (3 person family maximum)		None	None	None	None	None	None
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Preventive Care for Babies and Children (through age 5)		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Preventive Screenings for Adults		Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Mammograms		Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Maternity		NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED
Outpatient Medical Care		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Short Term Therapies: Physical/Occupational/Speech Respiratory Therapy, Cardiac and Pulmonary Rehabilitation (no limit on # of visits)		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Chiropractic Services (24 visits per year - Care must be received from ActivHealth Provider)		Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Infusion Therapy/Chemotherapy		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Emergency Room Care - For Medical Emergency or Serious Accidental Injury		$150 copay then 100% coverage	$150 copay then 100% coverage	$150 copay then 100% coverage	$150 copay then 100% coverage	$150 copay then 100% coverage	$150 copay then 100% coverage
Urgent Care		$55 Copay	$55 Copay	$55 Copay	$55 Copay	$55 Copay	$55 Copay
Ambulatory Surgical Center		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Ambulance Service		$150	$150	$150	$150	$150	$150
Hospice		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Home Health Care - Limited to 30 days, in and out of network combined		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Durable Medical Equipment, Prosthetics and Orthoses limited to $2,500 annual max, all combined		Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Skilled Nursing Facility Limited to 30 days, in and out of network combined		Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.	Paid at 60% after deductible is met.
Transplants		Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only
	Tier 2 (Formulary Brand)	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only
	Tier 3 (Non-Formulary Brand)	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only
	Tier 4 (self edministered injectables)	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only	Participating Pharmacies only
Dental ( all care must be received from a DeltaCare provider.		DeltaCare providers only	DeltaCare providers only	DeltaCare providers only	DeltaCare providers only	DeltaCare providers only	DeltaCare providers only
Vision - one exam every 12 months (care must be received from an Avesis provider)		Avesis Providers only	Avesis Providers only	Avesis Providers only	Avesis Providers only	Avesis Providers only	Avesis Providers only
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)
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