Georgia Individual HSA Coventry-One POS Out-of-Network Benefits

Your Out-of-Network CoventryOne Open Access POS QHD (HSA Qualified High Deductible)
Benefits At A Glance

Major Medial Insurance Company

CoventryOne Open Access POS QHD Out-of-Network Benefit Summary*
(click here for in-network benefit summary)

Description of Benefits
Unless otherwise stated, all benefits
are payable after yearly deductible is met
$1,250 Ind /
$2,550 Family Ded. 100/60% Plan
$3,000 Ind /
$5,000 Family Ded. 100/60% Plan
$5,000Ind /
$10,000 Family Ded. 100/60% Plan

Lifetime Maximum Per Member
$6,000,000
$6,000,000
$6,000,000

Out of Network Annual Deductible
$2,500 Individual /
$5,000 Family
$6,000 Individual /
11,000 Family
$10,000 Individual /
$20,000 Family

Annual Maximum Out of Pocket
$2,500 Individual /
$5,000 Family
(plus deductible)
$6,000 Individual /
11,000 Family
(plus deductible)
$10,000 Individual /
$20,000 Family
(plus deductible)

Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Preventive Care for Babies and Children (through age 5)
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Preventive Screenings for Adults
(unlimited yearly max)
Colonscopy will be paid at 100% after the yearly deductible is met.
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Mammograms
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Professional Services
Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Inpatient Hospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Maternity
NOT COVERED
NOT COVERED
NOT COVERED

Outpatient Medical Care
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Short Term Therapies:
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
(no limit on # of visits)
Developmental Delay is not covered
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Chiropractic Services
Not Covered
Not Covered
Not Covered

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

Infusion Therapy/Chemotherapy
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Emergency Room Care -
For Medical Emergency or Serious Accidental Injury
(Non emergency use of the emergency
room is not a covered benefit)
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met

Urgent Care
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met

Ambulatory Surgical Center
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Ambulance Service
(Emergency or Medically Necessary Only)
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met
Plan pays 100% after deductible is met

Hospice
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Home Health Care -
Limited to 30 days, in and out of network combined
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Durable Medical Equipment, Prosthetics and Orthoses
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Skilled Nursing Facility
Limited to 30 days, in and out of network combined
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met
Plan pays 60% after deductible is met

Transplants
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Prescription Drugs -
Retail Drugs - per prescription (up to a 30-day supply-mail order available)
After annual deductible is met, you pay:
After annual deductible is met, you pay:
After annual deductible is met, you pay:

Tier 1 (Generic Drugs)
$10 copayment
$10 copayment
$10 copayment

Tier 2 (Formulary Brand)
$70 copayment
$70 copayment
$70 copayment

Tier 3 (Non-Formulary Brand)
$150 copayment
$150 copayment
$150 copayment

Tier 4 (self edministered injectables)
Must be obtained in-network for benefit
Must be obtained in-network for benefit
Must be obtained in-network for benefit

Dental ( all care must be received from a DeltaCare provider.
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

Vision - one exam every 12 months (care must be received from an Avesis provider)
Not Covered OON - Must get service at an in-network provider for benefit Not Covered OON - Must get service at an in-network provider for benefit
Not Covered OON - Must get service at an in-network provider for benefit

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)

Click here for monthly insurance rates and an individual health insurance quote

Click here to have an enrollment kit mailed or emailed to you (be sure to specify which plan you're interested in)

CLICK HERE TO DOWNLOAD AND PRINT AN APPLICATION
(Adobe Acrobat reader is necessary to download this file.)
Click here to download the free Adobe Acrobat reader

9 Dunwoody Park
Suite 136
Atlanta, GA 30338
Call Holly, Chris or Bob at
(770) 396-9517
Outside of the Atlanta area,
call toll-free:
1-877-711-8376.
Email: holly@insurance-now.com

CoventryOne Open Access POS QHD Out-of-Network Benefit Summary* (click here for in-network benefit summary)
Description of Benefits Unless otherwise stated, all benefits are payable after yearly deductible is met		$1,250 Ind / $2,550 Family Ded. 100/60% Plan	$3,000 Ind / $5,000 Family Ded. 100/60% Plan	$5,000Ind / $10,000 Family Ded. 100/60% Plan
Lifetime Maximum Per Member		$6,000,000	$6,000,000	$6,000,000
Out of Network Annual Deductible		$2,500 Individual / $5,000 Family	$6,000 Individual / 11,000 Family	$10,000 Individual / $20,000 Family
Annual Maximum Out of Pocket		$2,500 Individual / $5,000 Family (plus deductible)	$6,000 Individual / 11,000 Family (plus deductible)	$10,000 Individual / $20,000 Family (plus deductible)
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Preventive Care for Babies and Children (through age 5)		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Preventive Screenings for Adults (unlimited yearly max) Colonscopy will be paid at 100% after the yearly deductible is met.		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Mammograms		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Maternity		NOT COVERED	NOT COVERED	NOT COVERED
Outpatient Medical Care		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Short Term Therapies: Physical/Occupational/Speech Respiratory Therapy, Cardiac and Pulmonary Rehabilitation (no limit on # of visits) Developmental Delay is not covered		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Chiropractic Services		Not Covered	Not Covered	Not Covered
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
Infusion Therapy/Chemotherapy		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Emergency Room Care - For Medical Emergency or Serious Accidental Injury (Non emergency use of the emergency room is not a covered benefit)		Plan pays 100% after deductible is met	Plan pays 100% after deductible is met	Plan pays 100% after deductible is met
Urgent Care		Plan pays 100% after deductible is met	Plan pays 100% after deductible is met	Plan pays 100% after deductible is met
Ambulatory Surgical Center		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Ambulance Service (Emergency or Medically Necessary Only)		Plan pays 100% after deductible is met	Plan pays 100% after deductible is met	Plan pays 100% after deductible is met
Hospice		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Home Health Care - Limited to 30 days, in and out of network combined		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Durable Medical Equipment, Prosthetics and Orthoses		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Skilled Nursing Facility Limited to 30 days, in and out of network combined		Plan pays 60% after deductible is met	Plan pays 60% after deductible is met	Plan pays 60% after deductible is met
Transplants		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		After annual deductible is met, you pay:	After annual deductible is met, you pay:	After annual deductible is met, you pay:
	Tier 1 (Generic Drugs)	$10 copayment	$10 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$70 copayment	$70 copayment	$70 copayment
	Tier 3 (Non-Formulary Brand)	$150 copayment	$150 copayment	$150 copayment
	Tier 4 (self edministered injectables)	Must be obtained in-network for benefit	Must be obtained in-network for benefit	Must be obtained in-network for benefit
Dental ( all care must be received from a DeltaCare provider.		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
Vision - one exam every 12 months (care must be received from an Avesis provider)		Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit	Not Covered OON - Must get service at an in-network provider for benefit
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)
Click here for monthly insurance rates and an individual health insurance quote Click here to have an enrollment kit mailed or emailed to you (be sure to specify which plan you're interested in)
CLICK HERE TO DOWNLOAD AND PRINT AN APPLICATION (Adobe Acrobat reader is necessary to download this file.) Click here to download the free Adobe Acrobat reader

9 Dunwoody Park Suite 136 Atlanta, GA 30338	Call Holly, Chris or Bob at (770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: holly@insurance-now.com