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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 |
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 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) |
| 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 |  |
 |
|
|
| 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. |
||||
| 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 |