| Company/Plan Name |
ExpressMed Saver PPO 50 |
| Deductible |
|
| In-Network |
$10,000
Per Person, Per Calendar Year |
| Out-Network |
$30,000
Per Person, Per Calendar Year, accumulates separately from In-Network Deductible |
| Maximum Family Deductible |
3 Per Family, Per Calendar Year |
| Coinsurance |
|
| In-Network |
50/50% to $10,000 |
| Out-Network |
30/70% to $10,000 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$5,000 excluding Deductible |
| Out-Network |
$7,000 excluding Deductible and expenses above usual & customary |
| Maximum Benefit |
$3,000,000 Lifetime |
| Physician Office Visit |
|
| In-Network |
$45 CoPay
Applies to office visit charges only |
| Out-Network |
Subject to Deductible and CoInsurance
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Subject to Deductible and CoInsurance after $250 access fee (maximum of four per covered person, per calendar year) |
| Out-Network |
Subject to Deductible and CoInsurance after $250 access fee (maximum of four per covered person, per calendar year) |
| Outpatient Preventive Care |
|
| In-Network |
Not Covered (or subject to state mandate) |
| Out-Network |
Not Covered (or subject to state mandate) |
| Prescription Drugs |
|
| Generic |
$15 CoPay |
| Brand Name(formulary) |
$50 CoPay after separate $1,000 deductible per person, per calendar year |
| Brand Name(Non-formulary) |
$50 CoPay after separate $1,000 deductible per person, per calendar year |
| Outpatient Surgery |
|
| In-Network |
Subject to Deductible and CoInsurance after $250 access fee (maximum of four per covered person, per calendar year) |
| Out-Network |
Subject to Deductible and CoInsurance after $250 access fee (maximum of four per covered person, per calendar year) |
| Emergency Room |
|
| In-Network |
Subject to Deductible & CoInsurance AFTER a $250 additional copayment. Access fee waived if admitted directly as inpatient. |
| Out-Network |
Subject to Deductible & CoInsurance AFTER a $250 additional copayment. Access fee waived if admitted directly as inpatient. |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not Covered (See brochure for complications of pregnancy) |
| Out-Network |
Not Covered (See brochure for complications of pregnancy) |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
Subject to Deductible and CoInsurance after $500 access fee (maximum of 4 per covered person, per calendar year) |
| Out-Network |
Subject to Deductible and CoInsurance after $500 access fee (maximum of 4 per covered person, per calendar year) |
| Surgical |
|
| In-Network |
Subject to Deductible and CoInsurance after $500 access fee (maximum of 4 per covered person, per calendar year) |
| Out-Network |
Subject to Deductible and CoInsurance after $500 access fee (maximum of 4 per covered person, per calendar year) |
| Maternity |
|
| In-Network |
Not covered (see brochure for complications of pregnancy) |
| Out-Network |
Not covered (see brochure for complications of pregnancy) |
| Rate Guarantee |
Initial 12 month rate guarantee |
| Optional Benefits |
|
| Supplemental Accident |
Optional $500, $1,000, $1,500, $2,000, $2,500, $3,000 or $5,000 Outpatient Accident Benefit Per Person, Per Calendar Year, then subject to Deductible & CoInsurance (not quoted - not all benefit levels are available in all states, refer to the ExpressMed brochure) |
| 24 Hour Coverage |
Included (See Brochure) |
| Other |
Not Quoted - Annually renewable term life insurance in amounts of $10,000, $25,000, or $50,000 (Not available in GA, OH or OK.) |
