CoventryOne Authorized Agent

 
770-396-9517

CoventryOne POS In-Network Benefit Summary*
$45 Copay Plans

Description of Benefits

$45 Copay Plan
$1,750 Deductible

$45 Copay Plan
$2,750 Deductible

$45 Copay Plan
$3,750 Deductible

$45 Copay Plan
$5,750 Deductible

 
Lifetime Maximum Per Member

Unlimited

Unlimited

Unlimited

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

$1,750

$2,750

$3,750

$5,750
Benefit Year Out-of-Pocket Maximum
(3 person family maximum)

$5,000 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 $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

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 100% 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/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/yr) Plan Pays Up to $25/visit (limit 6/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
(MRI, CT or PET Scans Paid at 70% after Deductible)

$500 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)

$500 copay (waived if admitted)
Convenience Care Clinic

$45 Ccpay

$45 Ccpay

$45 Ccpay

$45 Ccpay
 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

$500 Copay

$500 Copay

$500 Copay

$500 Copay
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)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)

Choice of $1000 or $0 Deductible
for Tiers 2, 3 & 4 (Tier 1 is Always $0 Deductible)
P
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N		 Tier 1 (Generic Drugs)
(AVAILABLE WITHOUT MEETING
ANY DEDUCTIBLE)

$15 copayment

$15 copayment

$15 copayment

$15 copayment
Tier 2 (Formulary Brand)

$40 copayment

$40 copayment

$40 copayment

$40 copayment
Tier 3 (Non-Formulary Brand)

$60 copayment

$60 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

$45 Copay Plan
$1,750 Deductible

$45 Copay Plan
$2,750 Deductible

$45 Copay Plan
$3,750 Deductible

$45 Copay Plan
$5,750 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)


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

Call Holly or Chris 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