Your In-Network CoventryOne Open Access POS Benefits At A Glance

Major Medial Insurance Company Authorized CoventryOne Agent

CoventryOne Open Access POS In-Network Benefit Summary* (click here for out-of-network benefit summary)
Description of Benefits		$500	$1,000	$2,000	$3,000	$4,000	$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	$6,000,000
Annual Deductible Per Member (3 person maximum)		$500	$1,000	$2,000	$3,000	$4,000	$5,000	$10,000
Annual Out-of-Pocket Maximum (3 person family maximum)		$2,500 plus deductible per member	$2,500 plus deductible per member	$2,500 plus deductible per member	$2,500 plus deductible per member	$2,500 plus deductible per member	$2,500 plus deductible per member	$2,500 plus deductible per member
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		$20/$55	$20/$55	$20/$55	$20/$55	$20/$55	$20/$55	$20/$55
Preventive Care for Babies and Children (through age 5)		$20	$20	$20	$20	$20	$20	$20
Preventive Screenings for Adults (unlimited yearly max) Colonscopy will be paid at 70% after the yearly deductible is met.		$20	$20	$20	$20	$20	$20	$20
Mammograms		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	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	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	Plan pays 70% after deductible	Plan pays 70% after deductible
Maternity		NOT COVERED	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 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	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	$10	$10	$10
Mental Health- Available only by purchase of an additional rider for $20.73/month (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	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	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)		$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	$150 copay then 100% coverage
Urgent Care		$55 Copay	$55 Copay	$55 Copay	$55 Copay	$55 Copay	$55 Copay	$55 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	Plan pays 70% after deductible	Plan pays 70% after deductible
Ambulance Service		$150	$150	$150	$150	$150	$150	$150
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	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	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	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	Plan pays 70% after deductible	Plan pays 70% after deductible
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	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 $100 deductible per person, you pay:	After a $250 deductible per person, you pay:	After a $250 deductible per person, you pay:	After a $250 deductible per person, you pay:	After a $250 deductible per person, you pay:	After a $500 deductible per person, you pay:	After a $1,000 deductible per person, you pay:
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	$10 copayment	$10 copayment	$10 copayment	$10 copayment	$10 copayment	$10 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$35 copayment	$35 copayment	$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	$50 copayment	$50 copayment
	Tier 4 (self edministered injectables)	$100 copayment	$100 copayment	$100 copayment	$100 copayment	$100 copayment	$100 copayment	$100 copayment
Dental ( all care must be received from a DeltaCare provider.		Various Copays	Various Copays	Various Copays	Various Copays	Various Copays	Various Copays	Various Copays
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	$15 Copay
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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