Coventry – Gold $15 Copay
Gold $15 Copay
Important Questions |
Answers |
Why This Matters: |
What is the overall deductible? |
In-Network: $1,400 Individual (Ind)/ $2,800 Family. Does not apply to: Certain office visits, Preventive Care (PC), Urgent care |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. |
Are there other deductibles for specific services? |
Yes, In-Network: $250 deductible, Out-ofNetwork: $500 deductible for prescription drugs. There are no other specific deductibles. |
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
Is there an out-of-pocket limit on my expenses? |
In-Network: Yes, $4,950 Ind/ $9,900 |
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. |
What is not included in the outof-pocket limit? |
Premiums, balance-billed charges, health care this plan does not cover |
Even though you pay these expenses, they don’t count toward the out-ofpocket limit. |
Is there an overall annual limit on what the plan pays? |
No |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
Does this plan use a network of providers? |
Yes |
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. |
Do I need a referral to see a specialist? |
No |
You can see the specialist you choose without permission from this plan. |
Are there services this plan doesn’t cover? |
Yes |
Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services. |
Common |
Services You May Need |
Your Cost If |
Your Cost If You Use a |
Limitations & Exceptions |
If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
$15 co-payment (co-pay)/visit deductible waived |
50% co-insurance |
———-none———- |
Specialist visit |
$35 co-pay/visit deductible waived |
50% co-ins |
———-none———- |
|
Other practitioner office visit |
20% co-ins chiropractor |
50% co-ins |
Coverage is limited to 12 visits per calendar year. |
|
Preventive care/ |
No Charge |
50% co-ins |
———-none———- |
|
If you have a test |
Diagnostic test (x-ray, blood work) |
20% co-ins x-ray |
50% co-ins x-ray |
———-none———- |
Imaging (CT/PET scans, MRIs) |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
|
If you need drugs to treat your illness or condition. |
Generic drugs |
$3 co-pay/Retail, |
50% co-ins/Retail, |
Limited to 31 day supply retail, 32-90 day supply mail.Non-Preferred Generic same benefit as NonPreferred Brand. |
Preferred brand drugs |
$40 co-pay/Retail, |
50% co-ins/Retail, |
Limited to 31 day supply retail, 32-90 day supply mail. |
|
If you need drugs to treat your illness or condition. |
Non-preferred brand drugs |
$70 co-pay/Retail, |
50% co-ins/Retail, |
Limited to 31 day supply retail, 32-90 day supply mail. |
Specialty drugs |
40% co-ins/Retail, |
Not Covered |
Limited to 31 day supply retail. |
|
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
20% co-ins |
50% co-ins |
———-none———- |
Physician/surgeon fees |
20% co-ins |
50% co-ins |
———-none———- |
|
If you need immediate medical attention |
Emergency room services |
$250 co-pay/visit |
$250 co-pay/visit |
Co-pay waived if admitted. |
Emergency medical transportation |
20% co-ins |
20% co-ins |
———-none———- |
|
Urgent care |
$75 co-pay/visit deductible waived |
50% co-ins |
———-none———- |
|
If you have a hospital stay |
Facility fee (e.g., hospital room) |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
Physician/surgeon fee |
20% co-ins |
50% co-ins |
———-none———- |
|
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
$35 co-pay/visit deductible waived |
50% co-ins |
MHNet network must be used for In-Network benefit, please call 1-800-423-8070. |
Mental/Behavioral health inpatient services |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. MHNet network must be used for in-network benefit, please call 1-800-423-8070. |
|
Substance use disorder outpatient services |
$35 co-pay/visit deductible waived |
50% co-ins |
MHNet network must be used for In-Network benefit, please call 1-800-423-8070. |
|
Substance use disorder inpatient services |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. MHNet network must be used for in-network benefit, please call 1-800-423-8070. |
|
If you are pregnant |
Prenatal and postnatal care |
Prenatal: No Charge, Postnatal and Delivery: $250 co-pay/pregnancy deductible waived |
50% co-ins |
One time co-pay. |
Delivery and all inpatient services |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
|
If you need help recovering or have |
Home health care |
20% co-ins |
50% co-ins |
———-none———- |
Rehabilitation services |
Inpatient 20% coins |
Inpatient 50% co-ins Outpatient 50% coins |
Prior authorization may be required, please see your plan documents. |
|
Habilitation services |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
|
Skilled nursing care |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
|
Durable medical equipment |
50% co-ins |
50% co-ins |
———-none———- |
|
Hospice Service |
20% co-ins |
50% co-ins |
Prior authorization may be required, please see your plan documents. |
|
If your child needs dental or eye care |
Eye exam |
No charge |
50% co-ins |
Coverage is limited to 1 exam per calendar year. |
Glasses |
No charge |
50% co-ins |
Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year. |
|
Dental check-up |
Not Covered |
Not Covered |
Not Covered |
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
|
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
|