Coventry- Bronze Deductible Only HSA


Golden Rule Illinois Insurance Quotes Free Online Quote

Coventry- Bronze Deductible Only HSA

Bronze Deductible Only HSA Eligible

Important Questions

Answers

Why This Matters:

What is the overall deductible?

In-Network: $6,450 Individual (Ind)/ $12,900 Family. Does not apply to:
Preventive Care (PC)
Out-of-Network: $12,900 Ind/ $25,800 Family

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?

No

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

In-Network: Yes, $6,450 Ind/ $12,900
Family
Out-of-Network: No

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
Phone: 1-855-449-2889; www.coventryone.com

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
Medical Event

Services You May Need

Your Cost If
You Use a
In-Network Provider

Your Cost If You Use a
Out-of-Network
Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

0% co-insurance
(co-ins)

50% co-ins

———-none———-

Specialist visit

0% co-ins

50% co-ins

———-none———-

Other practitioner office visit

0% co-ins chiropractor

50% co-ins

Coverage is limited to 12 visits per calendar year.

Preventive care/
Screening/Immunization

No Charge

50% co-ins

———-none———-

If you have a test

Diagnostic test (x-ray, blood work)

0% co-ins x-ray
0% co-ins lab

50% co-ins x-ray
50% co-ins lab

———-none———-

Imaging (CT/PET scans, MRIs)

0% 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.
More information about prescription drug coverage is available at www.coventryone.com.

Generic drugs

0% co-ins/Retail,
0% co-ins/Mail,
Tier 1

50% co-ins/Retail,
Not Covered/Mail,
Tier 1

Limited to 31 day supply retail, 32-90 day supply mail.Non-Preferred Generic same benefit as NonPreferred Brand.

Preferred brand drugs

0% co-ins/Retail,
0% co-ins/Mail,
Tier 2

50% co-ins/Retail,
Not Covered/Mail,
Tier 2

Limited to 31 day supply retail, 32-90 day supply mail.

Non-preferred brand drugs

0% co-ins/Retail,
0% co-ins/Mail,
Tier 3

50% co-ins/Retail,
Not Covered/Mail,
Tier 3

Limited to 31 day supply retail, 32-90 day supply mail.

If you need drugs to treat your illness or condition.
More information about prescription drug coverage is available at www.coventryone.com.

Specialty drugs

0% co-ins/Retail,
Not Covered/Mail, Tier 4; 0% coins/Retail, Not Covered/Mail, Tier
5

Not Covered

Limited to 31 day supply retail.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

0% co-ins

50% co-ins

———-none———-

Physician/surgeon fees

0% co-ins

50% co-ins

———-none———-

If you need immediate medical attention

Emergency room services

0% co-ins

0% co-ins

———-none———-

Emergency medical transportation

0% co-ins

0% co-ins

———-none———-

Urgent care

0% co-ins

50% co-ins

———-none———-

If you have a hospital stay

Facility fee (e.g., hospital room)

0% co-ins

50% co-ins

Prior authorization may be required, please see your plan documents.

Physician/surgeon fee

0% co-ins

50% co-ins

———-none———-

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

0% co-ins

50% co-ins

MHNet network must be used for In-Network benefit, please call 1-800-423-8070.

Mental/Behavioral health inpatient services

0% 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

0% co-ins

50% co-ins

MHNet network must be used for In-Network benefit, please call 1-800-423-8070.

Substance use disorder inpatient services

0% 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: 0% co-ins pregnancy

50% co-ins

———-none———-

If you are pregnant

Delivery and all inpatient services

0% co-ins

50% co-ins

Prior authorization may be required, please see your plan documents.

If you need help recovering or have
other special health
needs

Home health care

0% co-ins

50% co-ins

———-none———-

Rehabilitation services

Inpatient 0% co-ins Outpatient 0% coins

Inpatient 50% co-ins Outpatient 50% coins

Prior authorization may be required, please see your plan documents.

Habilitation services

0% co-ins

50% co-ins

Prior authorization may be required, please see your plan documents.

Skilled nursing care

0% co-ins

50% co-ins

Prior authorization may be required, please see your plan documents.

Durable medical equipment

0% co-ins

50% co-ins

———-none———-

Hospice Service

0% 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

0% co-ins

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.)
  • Abortion
  • Acupuncture
  • Child/Dental check-up
  • Cosmetic Surgery
  • Dental care (Adult)
  • Long Term Care
  • Non-emergency care when traveling outide the U.S.
  • Routine eye care (Adult)
  • Routine foot care
  • Weight loss programs
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.)
  • Bariatric Surgery
  • Chiropractic Care
  • Hearing Aids
  • Infertility Treatment
  • Private-duty nursing