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Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 80,000 members. Learn more


Plan Description

 
Plan
Plan Anniversary December 31, 2020 December 31, 2020 December 31, 2020 December 31, 2020
Enrollment 18th of month Prior to Effective date 18th of month Prior to Effective date 18th of month Prior to Effective date 18th of month Prior to Effective date
Issue Ages 18-64 18-64 18-64 18-64
States Available Available in all 50 States Available in all 50 States Available in all 50 States Available in all 50 States
Network
Preventative Services 100% Coverage for Mandated Preventative Services
Adults | Woman | Children
100% Coverage for Mandated Preventative Services
Adults | Woman | Children
100% Coverage for Mandated Preventative Services
Adults | Woman | Children
100% Coverage for Mandated Preventative Services
Adults | Woman | Children
Primary Care Visit $0 Copay
1 Visit Cal/Yr.
$0 Copay
1 Visit Cal/Yr.
$20 Copay
(Max 3 Visits Per Cal/Yr.)
$20 Copay
(Max 3 Visits Per Cal/Yr.)
Specialist Office Visit Not Covered Not Covered $50 Copay
(Max 3 Visits Per Cal/Yr.)
$50 Copay
(Max 3 Visits Per Cal/Yr.)
Urgent Care Covered Under
Accident Indemnity
Not Covered $50 Copay
(Max 3 Visits Per Cal/Yr.)
$50 Copay
(Max 3 Visits Per Cal/Yr.)
Diagnostic X-Ray, LabCovered Under
Accident Indemnity
Not Covered $50 Copay
(Max 5 Visits Per Cal/Yr.)
$50 Copay
(Max 5 Visits Per Cal/Yr.)
CT Scan or MRICovered Under
Accident Indemnity
Not Covered $200 Copay
(Max 1 CT Scan or MRI Visits Per Cal/Yr.) *
$200 Copay
(Max 1 CT Scan or MRI Visits Per Cal/Yr.)
Accident Indemnity
View Accident Details
Not Covered Not Covered
View Accident Details
Hospital Indemnity Not Covered Not Covered Not Covered
View Hospital Details
Medical Bill Negotiation
View Details

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View Details
Prescription Drugs
Rx Formulary
View Citizens RX Formulary

View Citizens RX Formulary
View Formulary
View Citizens RX Formulary
View Formulary
View Citizens RX Formulary
View Formulary
Rx Benefits

Discount Pharmacy Card
No Deductibles, No Annual Maximums, No Exclusions, No Pre-Existing Conditions.

Ability to purchase a 90-day supply of maintenance medications at retail locations

31-Day Supplies on most prescriptions

Mail Order:
Mail order pharmacy services on both Generic and Brand Name drugs.

Generic:
Up to 30%-80% Savings

Brand Name:
Up to 30%-80% Savings.


Acute Formulary
$5.00 Copayment for Acute Formulary (immediate Need)
Medications for up to a 21 day supply

Chronic Formulary

(Maintenance Medications)
MAIL ORDER ONLY
Copays differ based upon medications $15, $30 or $45 for 90 day supply

Saveon Diabetes

Saveon Diabetes is our program for members with Diabetes in which they will get a FREE meter, low cost testing strips, lancets and more.
Tier 1
Low Cost Generics

$1 Copay

Tier 2
Generics

10% Coinsurance

Tier 3
Preferred Brand

20% Coinsurance

Tier 4
Non-Preferred Brand

40% Coinsurance

Tier 5
Generic and Preferred Specialty

10% Coinsurance
(Pays 90% up to a max of $150 per RX)

Tier 6
Non-Preferred Specialty

20% Coinsurance
(Pays 80% up to a max of $250 per RX)
Tier 1
Low Cost Generics

$1 Copay

Tier 2
Generics

10% Coinsurance

Tier 3
Preferred Brand

20% Coinsurance

Tier 4
Non-Preferred Brand

40% Coinsurance

Tier 5
Generic and Preferred Specialty

10% Coinsurance
(Pays 90% up to a max of $150 per RX)

Tier 6
Non-Preferred Specialty

20% Coinsurance
(Pays 80% up to a max of $250 per RX)
* 3D MRIs or Contrast Services for MRIs and CT Scans are not covered, pre-authorization required prior to scans.
** Hospitalization services must be obtained at an authorized PHCS Facility. Pre-Authorization required prior to admission for all in-patient, out-patient and surgical procedures.

ACCIDENT INDEMNITY

(Included with Bronze & Platinum Plans)

  • No limits, no max
  • Hospital pays out anytime hospitalized up to 365 days a year
  • Pays out for every accident
  • No industry exclusions
  • Guaranteed Issue
INPATIENT
Daily Hospital Confinement
Maximum

$150 / Day
365 Days

Hospital Admission
Per Hospital Confinement
$1,000
Daily Intensive Care
Maximum

$450 / Day
30 Days

Surgery: Abdominal, Thoracic, Tendon, Ligament, Rotator Cuff $750 / Day
Anesthesia $187.50 /Day
Continuous Care(1)
Maximum

$90 / Day
30 Days

OUTPATIENT
Physician's Office

$25 / Day
6 Per Calendar Year

Wellness Benefit $25 / Day
1 Per Calendar Year
Emergency Room $75 / Day
3 Per Calendar Year
Lab, EKG and other Diagnostic Tests $20 Per Test Day
1 Per Calendar Year
X-Ray, Echocardiography and Cardiovascular Ultrasound $20 Per Test Day
2 Per Calendar Year
Advanced Studies(2) $100 / Day
1 Per Calendar Year
Ambulatory Surgical Center $25 / Day
Surgery: Abdominal, Thoracic, Tendon, Ligament, Rotator Cuff $750 / Day
Anesthesia $187.50 /Day
Ambulance Services Ground $120 / Day
1 Per Calendar Year
Ambulance Services Air $1,000 / Day
1 Per calendar Year
Lodging Maximum $100 I Day
15 Per calendar Year
Prosthesis $500
Transportation $300 / Day
3 Per Calendar Year
Accidental Death $20,000
Accidental Death on Common earner $40,000
Dislocation Benefit $1,000
Fracture Benefit $1,000
Burn Benefit $7,500
Coma $10,000
Dismemberment $10,000
Paralysis $10,000
(1) Continuous Care means care received in a Skilled Nursing Facility, Rehabilitation Facility, Rehabilitation Un􀀃 or Home Health Care or Hospice. The Continuous Care must begin within 7 days following discharge from a hospital and be necessary to treat the same condition that caused the hosp􀀃alization. Benefits are payable for a period equal to the length of the preceding hospital stay not to exceed 30 days.

(2) Advanced studies tests consist of the following: Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Computed Axial Tomography (CAT Scans); Pos􀀃ron Emission Tomography (PET Scans); and Computed Tomography (CT scans).
   
(1) Injury facts. (2014). Itasca, IL: National Safety Council.

(2) Moore, B., Levit, K., & Elixhauser, A. (2014, October). Costs for Hospital Stays in the United States, 2012 #181. Retrieved March 02, 2017, from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb181-Hospital-Costs-United- States-2012.jsp
   
Underwritten by

HOSPITAL INDEMNITY

(Included with Platinum Plan Only)

 
  • All benefits are per calendar year.
  • Hospital Admission is per admission.
  • Guaranteed Isssue
Hospital Admission $2,500
Hospital Confinement $100 / Day
10 days Max
Wellness $50 / Year
Rehab (Continuous Care) $100 / Day
15 day max
Underwritten by
   





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