CoventryOne Authorized Agent
Questions? 770-396-9517

CoventryOne Individual Health Insurance
$3750 Deductible Individual Insurance Policy Options and Benefit Summary

Description of Benefits

$30 Copay Plan

$35 Copay Plan

$45 Copay Plan
$0 Deductible for Generic Tier 1 Prescriptions -
$1000 Brand Name Prescription Deductible

$45 Copay Plan
$0 Prescription Deductible Option
Lifetime Maximum Per Member

Unlimited

Unlimited

Unlimited

Unlimited
Benefit Year Deductible Per Member
(2 person maximum per family)

$3,750

$3,750

$3,750

$3,750
Benefit Year Out-of-Pocket Maximum
(2 person family maximum)

$3,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member

$5,000 plus deductible per member
Office Visits - (PCP Physicians and Specialists)

Primary Care Dr.Unlimited Visits - Pay $30

Specialist-Unlimited Visits - Pay $60

Visits include lab and x-ray charges when performed and billed by Drs. office

Primary Care Dr.Unlimited Visits - Pay $35

Specialist-First 2 Visits - Pay $50:
3+ Visits Pay $50 After Deductible

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible

Primary Care Dr.Unlimited Visits - Pay $45

Specialist-First 2 Visits - Pay $75:
3+ Visits Pay $75 After Deductible
Preventive Care for Babies and Children  Covered at 100% - no copay  Covered at 100% - no copay  Covered at 100% - no copay  Covered at 100% - no copay
Preventive Screenings for Adults
(unlimited yearly max)- NOTE: Colonscopy will be paid at 70% after the yearly deductible is met however Colon Screenings are covered at 100%		  Covered at 100% - no copay  Covered at 100% - no copay  Covered at 100% - no copay  Covered at 100% - no copay
Mammograms
Preventive and Diagnostic		 Covered at 100% - no copay Covered at 100% - no copay Covered at 100% - no copay Covered at 100% - no copay
Professional Services
Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Inpatient Hospital Services
Surgery, x-ray, in-hospital physician visits, organ/tissue transplants

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Maternity

NOT COVERED

NOT COVERED

NOT COVERED

NOT COVERED
Outpatient Medical Care

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Short Term Therapies:
Physical/Occupational-24 visit limit/yr
Cardiac and Pulmonary Rehabilitation-
30 visits; Speech-24 visits
Developmental Delay is not covered

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Chiropractic Services - (6 visits per year - Care must be received from ActivHealth Provider) Plan Pays Up To $25 per Visit (6 visits/yr) Plan Pays Up To $25 per Visit (6 visits/yr) Plan Pays Up To $25 per Visit (6 visits/yr) Plan Pays Up To $25 per Visit (6 visits/yr)
 Mental Health- Available only by purchase of an additional rider
(rider gives 48 O/P Vis & 30 I/P days per yr.)		 Optional rider available for additional $43/month Optional rider available for additional $43/month Optional rider available for additional $43/month Optional rider available for additional $43/month
Infusion Therapy/Chemotherapy

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Emergency Room Care -
For Medical Emergency or Serious Accidental Injury

$250 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)
Convenience Care Clinic

$30

$35

$45

$45
 Urgent Care Facility Services

$75 Copay

$75 Copay

$75 Copay

$75 Copay
Ambulatory Surgical Center

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Ambulance Service

$250

$250

$500

$500
Hospice

Plan pays 70% with deductible waived

Plan pays 70% with deductible waived

Plan pays 70% with deductible waived

Plan pays 70% with deductible waived
Durable Medical Equipment, Prosthetics and Orthoses
limited to $2,500 annual max, all combined

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Skilled Nursing Facility
Limited to 30 days, in and out of network combined

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Transplants - (Unlimited Benefit)

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Prescription Drugs -
Retail Drugs - per prescription (up to a 30-day supply-mail order available)

Generic (Tier 1) prescriptions are available without meeting a deductible.
For brand prescriptions, a $500 deductible per person will apply. After deductible is met, you pay:

Generic (Tier 1) prescriptions are available without meeting a deductible.
For brand prescriptions, a $1,000 deductible per person will apply. After deductible is met, you pay:

Generic (Tier 1) prescriptions are available without meeting a deductible.
For brand prescriptions, a $1,000 deductible per person will apply. After deductible is met, you pay:

$0 Deductible
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N		 Tier 1 (Generic Drugs)
(AVAILABLE WITHOUT MEETING
ANY DEDUCTIBLE)

$10 copayment

$10 copayment

$15 copayment

$15 copayment
Tier 2 (Formulary Brand)

$35 copayment

$35 copayment

$40 copayment

$40 copayment
Tier 3 (Non-Formulary Brand)

$50 copayment

$50 copayment

$60 copayment

$60 copayment
Tier 4 (self edministered injectables)

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible

CoventryOne has an out of pocket maximum of $3000 that you will pay per person per year for your prescription medications at the most - Once your out-of-pocket maximum is met, CoventryOne will pay your prescriptions at 100% for the remainder of the year.
Vision - one exam every 12 months (care must be received from an Avesis provider)

$15 Copay

$15 Copay

$15 Copay

$15 Copay
Description of Benefits

$30 Copay Plan With Dental

$35 Copay Plan With Dental

$45 Copay Plan With Dental
$0 Deductible for Generic Tier 1 Prescriptions -
$1000 Brand Name Prescription Deductible

$45 Copay Plan With Dental
$0 Prescription Deductible Option

Waiting period for all undisclosed pre-existing conditions is at least one year from contract effective date.
*Premiums, deductibles and copays do not apply to out-of-pocket maximums. This summary is a partial description of coverage and does not detail all benefits, limitations and/or exclusions. Please consult member contract, schedule of benefits and/or insurance agents listed below for more information on pre-existing conditions and coverage limitations. All Applications are subject to medical underwriting review and approval. Refer to your individual certificate of coverage for complete benefit details. (As with all insurance providers, not disclosing known prexisting conditions could result in termination of your benefits)


Insurance Now
5 Dunwoody Park South
Suite 113
Atlanta, GA 30338

Call Holly, Chris or Bob at
(770) 396-9517
Outside of the Atlanta area,
call toll-free: 1-877-711-8376
fax: 770-396-4318
Email: holly@insurance-now.com