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Plan Description
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| Plan |  |
 |
 |
 |
| Plan Anniversary | September 1, 2021 | September 1, 2021 | September 1, 2021 | September 1, 2021 |
| Enrollment | 18th of month Prior to Effective date |
18th of month Prior to Effective date |
18th of month Prior |
18th of month Prior to Effective date |
| Issue Ages | 18+ | 18+ | 18+ | 18+ |
| 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) |
| 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 Services | Network Discount |
$50 Copay (Unlimited) |
$50 Copay (Unlimited) | $50 Copay (Unlimited) |
| X-Rays | Network Discount | $50 Copay (Unlimited) | $50 Copay (Unlimited) | $50 Copay (Unlimited) |
| * Exclusions | Office Visits do not include: Chiropractic Care, Physical Therapy, Occupational Therapy, Speech Therapy and Mental Health. | |||
| 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 |  |
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|
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| Rx Benefits | Discount Pharmacy Card Brand Name:
|
Generic RX Brand RX |
Generic RX Brand RX |
Generic RX Brand RX |
| 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. |
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| 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 |
| Pre-existing Condition Limitation | Does Not Apply | Does Not Apply | 3 month look back period, 6 months treatment free / 12 month exclusion period. | 3 month look back period, 6 months treatment free / 12 month exclusion period. |
| Treatment of Normal Pregnancy | Not Covered | Not Covered | Hospital Admission and Confinement Benefits are not payable for Birth within first 9 months of coverage. | Hospital Admission and Confinement Benefits are not payable for Birth within first 9 months of coverage. |
| 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 | $7,000 | $7,000 |
| Portability | Not Covered | Not Covered | Included | Included |
Access to the insurance plans and large group pricing on this website is predicated upon joining
Elevate Wellness, a national association with over 100,000 members.
Click here to Learn more
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