![]() A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. The Summary of Benefits & Coverage can be found at.Insurance companies reserve the right to change the terms of a policy upon proper notification. The insurance company always determines your actual premium. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The quotes or rates shown above are estimates only. Please check below for information regarding the plans and carriers you selected. These amounts are subject to change.Įach insurance carrier may have unique Notices, Disclaimers, and Fees. The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network. Only the terms and conditions of coverage benefits listed in the policy are binding. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. The information shown here is a summary of benefits for informational purposes only. Out-of-Network Annual Out-of-Pocket LimitĮlectronic Signature for Application Available Inpatient Hospital Services: 20% Coinsurance after deductible Inpatient Physician and Surgical Services: 20% Coinsurance after deductibleĢ0% Coinsurance after deductible, limited to 100 Days per Yearĥ0% Coinsurance, limited to 1 Item(s) per Year $65 Copay after deductible, limited to 60 Visit(s) per Year Outpatient Rehabilitation Services (PT, OT, ST) Outpatient Lab: $75 Copay after deductible X-rays: $75 Copay after deductible Outpatient Surgery Physician/Surgical Services: No Charge Outpatient Facility Fee: $1000 Copay after deductible ![]() Generic Drugs: $30 Copay Preferred Brand Drugs: 50% Coinsurance after deductible Non-Preferred Brand Drugs: 50% Coinsurance after deductible Specialty Drugs: 50% Coinsurance after deductible Off Label Prescription Drugs: 50% Coinsurance after deductible Office Visit for Other Practitioner (Nurse, Physician Assistant) Office Visit for Primary Doctor Find Doctors ![]()
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