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Plan Benefit Summary OneDeductible PPO Elite
Monthly Premium 139.90
Deductible Benefit Summary
2,850
Office Copay No
Coinsurance / Maximum Out-of-Pocket 80% (OOP: $2,000)
Lifetime Maximum 25Mil
PPO Network HLK - www.healthlink.com
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Maternity Coverage No Coverage
Outpatient Maximum
HSA Ready Yes
Plan Description The high deductible health plan with a single deductible for the whole family
Preventive Care / Wellness / Routine Physical Subject to the integrated deductible and plan coinsurance. Benefits for preventive medicine services are limited to a maximum calendar year benefit of $1,500 per covered person. The maximum will not apply to routine mammograms, routine pap tests, routine annual prostate specific antigen (PSA) tests, the annual exam for detection of prostate cancer, child screening tests and diagnostic follow up care for hearing loss, and child immunizations. Child immunizations are exempt from any deductible, copayment and/or coinsurance provisions. Child screening tests and diagnostic follow up for hearing loss are exempt from any deductible. If the Optional First Dollar Preventive Services Benefit is purchased (where available), the plan deductible and coinsurance will be waived for the first $500 of covered services performed by a participating provider for each covered person per calendar year after a 12-month benefit waiting period.
Doctor's Office Visits Subject to the integrated deductible and coinsurance.
Outpatient Lab Tests & X-rays Subject to the integrated deductible and coinsurance.
Outpatient Surgical Subject to the integrated deductible and coinsurance.
Prescription Drugs Subject to the integrated deductible and coinsurance.
Inpatient Services / Hospitalization Subject to the integrated deductible and coinsurance.
Emergency Room Services Covered charges are subject to the integrated deductible and coinsurance.
Ambulance Services Professional ground or air transportation in an ambulance for a covered person who needs emergency treatment for a sickness or an injury to the nearest acute medical facility that can treat the sickness or injury. The ambulance service must meet all applicable state licensing requirements. Subject to the integrated deductible and plan coinsurance.
Rehabilitation Services Inpatient: subject to the integrated deductible and coinsurance. Benefits are limited to a maximum calendar year benefit of 90 days per covered person. Outpatient: subject to the integrated deductible and coinsurance. Benefits are limited to an outpatient physical medicine services maximum calendar year benefit of $3,000 per covered person. Outpatient physical medicine services (rehabilitation services) include benefits for chiropractic care.
Chiropractic Services Subject to the integrated deductible and coinsurance. Benefits are included in the outpatient physical medicine provision which has a combined calendar year maximum of $3,000 per covered person.
Mental Nervous / Substance Abuse Subject to the integrated deductible and 50% coinsurance for participating providers, 70% coinsurance for non-participating providers. $2,500 calendar year maximum.
Complications of Pregnancy Covered charges are covered the same as any other illness.
Calendar Year Maximum None.
Plan Exclusions Exclusions consist of the following, but are not limited to: illness or injury caused by war (whether declared or undeclared), commission of a felony, attempted suicide, influence of an illegal substance, or a hazardous activity for which compensation is received; routine hearing care, vision care, surgery to correct vision, routine foot care or foot orthotics, except for podiatric appliances for the prevention of complications associated with diabetes; cosmetic services; routine dental care unless the dental insurance option is chosen; diagnosis and treatment of infertility; maternity and routine nursery charges unless the maternity option is chosen; growth hormone stimulation to promote or delay growth; genetic testing, counseling and services; charges to treat sexual dysfunction or inadequacy or to restore or enhance sexual performance or desire; over-the-counter products; charges related to "quality of life" or "lifestyle" concerns including, but not limited to: smoking cessation, obesity, hair loss, or cognitive enhancement; charges incurred due to a pre-existing condition until you have been continuously insured for 12 months (unless the condition has been specifically excluded from coverage).
Pre-Existing Condition
A Sickness or an Injury and related complications:
1. For which medical advice, diagnosis, care or treatment was sought, received or recommended from a provider or Prescription Drugs were prescribed during the 12-month period immediately prior to the Covered Person's Effective Date, regardless of whether the condition was diagnosed, misdiagnosed or not diagnosed; or
2. That produced symptoms during the 12-month period immediately prior to the Covered Person's Effective Date which reasonably should have caused or would have caused an ordinarily prudent person to seek diagnosis or treatment.
A pregnancy that exists on the day before the Covered Person's Effective Date will be considered a Pre-Existing Condition, subject to the Pre-Existing Condition definition. DEF: 500.002.TX
These rates are only valid for policies issued with effective dates from 5/1/2008 to 5/28/2008. Rates quoted for more than 30 days in advance of the effective date are subject to change and are not guaranteed. This proposal is not an insurance contract. Only the actual contract provisions will apply. Final rates may vary slightly due to the rounding process. The effective date on the quote does not guarantee coverage and is subject to change. The preferred rates are subject to final underwriting approval. Applicants may be subject to a pre-existing condition limitation on benefits. Refer to the certificate of insurance for terms and conditions.
For applicants under age 40, to qualify for preferred rates, cholesterol readings, if known, must be under 220 and blood pressure readings, if known, must be under 140/90 bp.
Preferred rates are not available to every customer. Generally, you must be in good health in order to receive the preferred rate. These rates are determined and subject to change based upon your application and medical history, our underwriting requirements, and any additional benefits you may select.
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