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CoventryOne POS Out-of-Network Benefit Summary* $7,500 and $10,000 Deductible Plan Options (click here for in-network benefit summary)
Description of Benefits (Out of Network Benefits)		$35 Copay Plan $7,500 Deductible	$35 Copay Plan $10,000 Deductible
Lifetime Maximum Per Member		Unlimited	Unlimited
Annual Deductible Per Member (3 person maximum)		$15,000	$20,000
Annual Out-of-Pocket Maximum (3 person family maximum)		NONE	NONE
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work only when performed and billed by the physician's office)		50%.	50%.
Preventive Care for Babies and Children (through age 5)		50%	50%
Preventive Screenings for Adults (unlimited yearly max) Colonscopy will be paid at 70% after the yearly deductible is met.		50%	50%
Mammograms Preventive and Diagnostic		50%	50%
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab.		50%	50%
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		50%	50%
Maternity		NOT COVERED	NOT COVERED
Outpatient Medical Care		50%	50%
Short Term Therapies: Physical/Occupational/Speech Respiratory Therapy, Cardiac and Pulmonary Rehabilitation (no limit on # of visits) Developmental Delay is not covered		50%	50%
Chiropractic Services (24 visits per year - Care must be received from ActivHealth Provider)		NOT COVERED	NOT COVERED
Mental Health- Available only by purchase of an additional rider (rider gives 48 O/P Vis & 30 I/P days per yr.)		Available only by purchasing a Rider	Available only by purchasing a Rider
Infusion Therapy/Chemotherapy		50%	50%
Emergency Room Care - For Medical Emergency or Serious Accidental Injury (Non emergency use of the emergency room is not a covered benefit)		$500	$500
Urgent Care		$75 Copay	$75 Copay
Ambulatory Surgical Center		50%	50%
Ambulance Service		50%	50%
Hospice		50%	50%
Home Health Care - Limited to 30 days, in and out of network combined		50%	50%
Durable Medical Equipment, Prosthetics and Orthoses limited to $2,500 annual max, all combined		50%	50%
Skilled Nursing Facility Limited to 30 days, in and out of network combined		50%	50%
Transplants (Unlimited Benefit)		NOT COVERED	NOT COVERED
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		Participating Pharmacies only	Participating Pharmacies only
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	Participating Pharmacies only	Participating Pharmacies only
	Tier 2 (Formulary Brand)	Participating Pharmacies only	Participating Pharmacies only
	Tier 3 (Non-Formulary Brand)	Participating Pharmacies only	Participating Pharmacies only
	Tier 4 (self edministered injectables)	Participating Pharmacies only	Participating Pharmacies only
Dental ( all care must be received from a DeltaCare HMO provider)		DeltaCare providers only	DeltaCare providers only
Vision - one exam every 12 months (care must be received from an Avesis provider)		Avesis Providers only	Avesis Providers only
Description of Benefits		$35 Copay Plan $7,500 Deductible	$35 Copay Plan $10,000 Deductible
Waiting period for all undisclosed pre-existing conditions is at least one year from contract effective date. *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)
Click here to apply online! Click here to have an enrollment kit mailed or e-mailed to you (be sure to specify which plan you're interested in)
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Insurance Now 9 Dunwoody Park Suite 136 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