     |
|
$35 Copay POS
Plans - Benefits
|
| Plans: |
$35/$1000 |
$35/$2500 |
$25/$5000 |
$35/$7500
Basic |
$35/$10000
Basic |
| Deductibles: |
$1000 |
$2500 |
$5000 |
$7500 |
$10000 |
Doctor Co-Pay
(in network) |
$35
$50 first 2 visits - specialist |
$35
$50 first 2 visits - specialist
|
$35
$50 first 2 visits - specialist
|
$35
$50 after deductible - specialist
|
$35
$50 after deductible - specialist
|
| Hospital Coinsurance: |
70/30% |
70/30% |
70/30% |
70/30% |
70/30% |
Coinsurance
(max out of pocket) |
$5000 - max 2 per family
|
$5000 - max 2 per family
|
$5000 - max 2 per family
|
$5000 - max 2
per family
|
$10000 - max 2
per family
|
| Preventive Care: |
$35 |
$35 |
$35 |
$35 |
$35 |
| Prescription Drugs: |
After $1000 prescription deductible
(NO DEDUCTIBLE ON GENERICS), then:
l $10 Copay Generic
l $35 Copay Brand
l $50 Copay Non-Preferred Brand
l 70% Copay Self-Administred Injectable Drugs |
After $2000 prescription deductible
(NO DEDUCTIBLE ON GENERICS), then:
l $10 Copay Generic
l $35 Copay Brand
l $50 Copay Non-Preferred Brand
l 70% Copay Self-Administred
Injectable Drugs |
| Maternity Coverage: |
Not covered |
Not covered |
Not covered |
Not covered |
Not covered |
| Lifetime Benefit: |
$7 million |
$7 million |
$7 million |
$7 million |
$7 million |
| Physician Network: |
Coventry |
Coventry |
Coventry |
Coventry |
Coventry |
|
Area
1 rates for: Banks, Barrow, Bartow, Bibb, Bleckley,
Burke, Butts, Cherokee, Clayton, Cobb, Columbia, Coweta,
Crawford, Dawson, Dekalb, Dooly, Douglas, Fayette, Forsyth,
Fulton, Greene, Gwinnett, Henry, Houston, Jasper, Jackson,
Jones, Lamar, Lincoln, Macon, McDuffie, Meriwether. Monroe,
Morgan, Newton, Paulding, Peach, Pike, Richmond, Rockdale,
Spalding, Taylor, Troup, Twiggs, Walton, and Wilkonson
counties
Area
2 rates for: Atkinson, Brantley, Brooks, Camden,
Carroll, Echols, Gilmer, Haralson, Heard, Lanier, Lowndes,
Pierce, and Ware counties.
Area
3 rates for: Appling, Bryan, Bulloch, Candler, Chatham,
Effingham, Emanuel, Evans, Liberty, Long, McIntosh, Screven,
Tattnall, and Wayne counties.
Area
4 rates for: Chattahoochee, Chatooga, Clarke, Floyd, Habersham,
Hall, Lumpkin, Madison, Muscogee, Oconee, Oglethorpe,
Pickens, Polk, White, and Wilkes counties.
|
