Coventry – Silver $15 Copay


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Coventry - Silver $15 Copay

Silver $15 Copay

Important Questions

Answers

Why This Matters:

What is the overall deductible?

In-Network: $3,500 Individual (Ind)/ $7,000 Family. Does not apply to: Certain office visits, Preventive Care (PC), Urgent  care
Out-of-Network: $7,500 Ind/ $15,000 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?

Yes, In-Network: $500 deductible, Out-ofNetwork: $1000 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, $6,200 Ind/ $12,400
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

$15 co-payment (co-pay)/visit deductible waived

50% co-insurance
(co-ins)

———-none———-

Specialist visit

$75 co-pay/visit deductible waived

50% co-ins

———-none———-

Other practitioner office visit

30% 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)

30% co-ins x-ray
30% co-ins lab

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

———-none———-

Imaging (CT/PET scans, MRIs)

$250 co-pay/service
+ 30% 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

$5 co-pay/Retail,
$12.50 co-pay/Mail, Tier 1a; $15 copay/Retail, $37.50 co-pay/Mail, Tier 1

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

$40 co-pay/Retail,
$100 co-pay/Mail,
Tier 2

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

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

Specialty drugs

40% co-ins/Retail,
Not Covered/Mail, Tier 4; 50% 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)

$250 co-pay/service
+ 30% co-ins

50% co-ins

———-none———-

Physician/surgeon fees

30% co-ins

50% co-ins

———-none———-

If you need immediate medical attention

Emergency room services

$500 co-pay/visit

$500 co-pay/visit

Co-pay waived if admitted.

Emergency medical transportation

30% co-ins

30% 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)

$500 co-pay/admit
+ 30% co-ins

50% co-ins

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

Physician/surgeon fee

30% co-ins

50% co-ins

———-none———-

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

Mental/Behavioral health outpatient services

$75 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

$500 co-pay/admit
+ 30% 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

$75 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

$500 co-pay/admit
+ 30% 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

$500 co-pay/admit
+ 30% 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

30% co-ins

50% co-ins

———-none———-

Rehabilitation services

Inpatient $500 copay/admit + 30% co-ins
Outpatient 30% coins

Inpatient 50% co-ins Outpatient 50% coins

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

Habilitation services

30% co-ins

50% co-ins

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

Skilled nursing care

30% 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

30% 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.)
  • 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