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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 States Available in All States Available in All States Available in All States
Dependent Age Limit Dependents to age 26 Dependents to age 26 Dependent to age 26 Dependent to age 26
Network
Wellness & Preventative 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
Telemedicine $0 Copay (Unlimited)



$0 Copay (Unlimited)

$0 Copay (Unlimited)

$0 Copay (Unlimited)

Virtual Behavioral Health Not Covered $50 Copay (3X/year) $50 Copay (3X/year) $0 Copay (Unlimited)
Primary Care Visits $15 Copay (Unlimited) $15 Copay (Unlimited) $15 Copay (Unlimited) $15 Copay (Unlimited)
Specialist Office Visits Network Discount $15 Copay (Unlimited) $15 Copay (Unlimited) $15 Copay (Unlimited)
Urgent Care Visits $50 Copay (Unlimited) $50 Copay (Unlimited) $50 Copay (Unlimited) $50 Copay (Unlimited)
Lab ServicesNetwork Discount

$50 Copay (Unlimited)

$50 Copay (Unlimited) $50 Copay (Unlimited)
X-RaysNetwork Discount $50 Copay (Unlimited) $50 Copay (Unlimited) $50 Copay (Unlimited)
Discount Bundle Dental - Vision - DME
Diabetic - Hearing - Fitness
Dental - Vision - DME
Diabetic - Hearing - Fitness
Dental - Vision - DME
Diabetic - Hearing - Fitness
Dental - Vision - DME
Diabetic - Hearing - Fitness
Prescription Drugs
Rx Formulary View Citizens RX Formulary View RX Formulary View RX Formulary View RX Formulary
Rx Benefits

Discount Pharmacy Card

Generic:
Up to 30%-80% Savings

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


Generic RX
Tier 1: $10 Copay
Tier 2: $25 Copay

Brand RX
Tier 1: $50 Copay
Tier 2: $75 Copay

Generic RX
Tier 1: $10 Copay
Tier 2: $25 Copay

Brand RX
Tier 1: $50 Copay
Tier 2: $75 Copay

Generic RX
Tier 1: $10 Copay
Tier 2: $25 Copay

Brand RX
Tier 1: $50 Copay
Tier 2: $75 Copay

Hospital - Surgical Indemnity Reimbursement - Underwritten By MetLife
  If a plan benefit is listed as an indemnity reimbursement:
An Indemnity plan reimburses an insured after they submit a claim for a covered medical expense. This reimbursement pays the insured in addition to and regardless of any other insurance the insured may have.
Admission Benefit Not Covered Not Covered $2,000 (1x/Yr.)
Indemnity Reimbursement
$2,500 (1x/Yr.)
Indemnity Reimbursement
Confinement Benefit Not Covered Not Covered $50 /Day (30x/Yr.)
Indemnity Reimbursement
$200 /Day (30x/Yr.)
Indemnity Reimbursement
Inpatient Rehabilitation Not Covered Not Covered Not Covered $100 /Day (15x/Yr.)
Indemnity Reimbursement
Inpatient Surgery Not Covered Not Covered Not Covered $1,000 (1x/Yr.)
Indemnity Reimbursement
Outpatient Surgery Not Covered Not Covered $250/$500 (1x/Yr.)
Indemnity Reimbursement
$750/$1,500 (1x/Yr.)
Indemnity Reimbursement
Diagnostic Procedure Not Covered Not Covered $250(1x/Yr.)
Indemnity Reimbursement
$250(1x/Yr.)
Indemnity Reimbursement
Emergency Room Not Covered Not Covered Not Covered $100/Day (1x/Yr.)
Indemnity Reimbursement
Other Benefits
Ambulance Benefit Not Covered Not Covered Not Covered $500Air Trans. (2x/Yr.) $200 ground trans (2x/Yr.)
Indemnity Reimbursement
Health Screening
(Outpatient Benefit)
Not Covered Not Covered Not Covered $50 (1x/Yr.)
Indemnity Reimbursement
Life Insurance Not Covered Not Covered $10,000 $10,000
Portability Not Covered Not Covered Included Included





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