Coventry Health Insurance Georgia - $2,000 and $2,500 Deductible Options

Coventry One Health Insurance Georgia POS In-Network Benefit Summary

$2,000 and $2,500 Deductible Options

Description of Benefits

$30 Copay Plan
$2,000 Deductible

MOST POPULAR PLAN!
$45 Copay Plan
$2,500 Deductible

HDHP(HSA)
$1,250 Single Ded.
$2,500 Fam. Ded.
OfficeVisits - (PPOPhysicians and Specialists-includes X-ray and lab work onlywhen performed and billed by the physician's office)

$20/$55

$35Family Dr.(unlimited vis)
$50 Specialist (2 vis/yr
then meet deductible)

Deductible
LifetimeMaximum Per Member

$6,000,000

$7,000,000

$6,000,000
AnnualDeductible Per Member
(3person maximum)

$2,000

$2,500

$1,250
AnnualOut-of-Pocket Maximum
(3person family maximum)

$2,500plus deductible per member

$5,000plus deductible per member

$1,250plus deductible per member
PreventiveCare for Babies and Children (throughage 5)

$20

$35

$20
PreventiveScreenings for Adults
(unlimited yearly max)
Colonscopywill be paid at 70% after the yearly deductible is met.

$20

$35

$20
Mammograms
Preventive and Diagnostic

Coveredat 100% - no copay

Coveredat 100% - no copay
 Coveredat 100% - no copay
ProfessionalServices
Including surgery, anesthesia, in-hospital physician care, diagnosticX-ray and lab.

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
InpatientHospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
Maternity

NOTCOVERED

NOTCOVERED

NOTCOVERED
OutpatientMedical Care

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
ShortTerm Therapies:
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
(nolimit on # of visits)
Developmental Delay is not covered

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
Chiropractic Services
(24 visits per year - Care must be received from ActivHealthProvider)
 $10  $10 NOT COVERED
Mental Health-
Available only by purchase of an additional rider
(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 
InfusionTherapy/Chemotherapy

Planpays 70% after deductible

Planpays 70% after deductible

Deductible

EmergencyRoom Care -

ForMedical Emergency or Serious Accidental Injury
(Non emergency use of the emergency
room is not a covered benefit)

$150 copay then 100% coverage $250 copay then 100% coverage

Deductible
 UrgentCare

$55Copay

$75Copay

Deductible
AmbulatorySurgical Center

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
AmbulanceService

$150

Planpays 70% after deductible

Deductible
Hospice

Planpays 70% with deductible waived

Planpays 70% with deductible waived

Deductible
Home HealthCare -
Limited to 30 days, in and out of network combined

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
DurableMedical Equipment, Prosthetics and Orthoses
limitedto $2,500 annual max, all combined

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
SkilledNursing Facility
Limited to 30 days, in and out of network combined

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
Transplants
(Unlimited Benefit)

Planpays 70% after deductible

Planpays 70% after deductible

Deductible
PrescriptionDrugs -
Retail Drugs - per prescription (up to a 30-day supply-mail orderavailable)

After a $250 deductible per person, you pay:

After a $1,000 deductible per person, you pay:

After deductible per person, you pay:
Tier 1(Generic Drugs)
(Available without meeting any deductible.)

$10copayment

$10copayment

$10copayment
Tier 2(Formulary Brand)

$35copayment

$35copayment

$35copayment
Tier 3(Non-Formulary Brand)

$50copayment

$50copayment

$50copayment
Tier 4(self edministered injectables)

$100copayment

$100copayment

$100copayment
Dental ( all care must be received from a DeltaCare HMOprovider)

VariousCopays

NotIncluded

VariousCopays
Vision - one exam every 12 months (care must bereceived from an Avesis provider)

$15Copay

NotIncluded

$15Copay

Description of Benefits

$20 Copay Plan
$2,000 Deductible

MOST POPULAR PLAN!
$35 Copay Plan
$2,500 Deductible

HDHP(HSA)
$1,250 Single Ded.
$2,500 Fam. Ded.

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