Saver 80 – Benefit Summary

Saver 80 – Benefit Summary

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Plan Feature	In-Network
Deductible Maximum 2 per family, per calendar year	$1,000 single / $2,000 family $1,500 single / $3,000 family $2,500 single / $5,000 family $5,000 single / $10,000 family $7,500 single / $15,000 family $10,000 single / $20,000 family
Coinsurance Choices The level of coverage provided by the plan after the calendar year Deductible has been satisfied.	You pay 20%
Coinsurance Out-of-Pocket Maximum In-network, per person, per calendar year, after deductible.	$3,000
Lifetime Maximum Benefit	Unlimited
Initial Rate Guarantee	12 Months
Physicians (illness and injury)
Office Visits Primary Care or Specialist	Not covered
Wellness/Preventive Care Benefits	100% (deductible waived)
Doctor Office Visit Adult or child, in-network only.	Not covered
X-Ray and Lab In conjunction with the preventive office visit, performed in doctor’s office or network facility.	Not covered
Child Immunizations Ages 0-18.	Covered at 100% (deductible waived)
Preventive Mammorgram, Pap Smear, PSA screening No waiting period.	Covered at 100% (deductible waived)
Outpatient Expense Benefits
X-Ray and Lab Must be performed within 14 days of surgery or confinement	You pay 20% after deductible
Facility/Hospital for Outpatient Surgery Surgery in doctor’s office not covered	You pay 20% after deductible
Surgeon, Assistant Surgeon, and Facility Fees	You pay 20% after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs	You pay 20% after deductible
Emergency Room Fees – Illness	You pay $500 copay if not admitted, then 20% after deductible
Emergency Room Fees – Injury	You pay $500 copay if not admitted, then 20% after deductible
Spine and Back Disorders CAT scan and MRI tests not subject to this limitation.	Not covered
Mental and Nervous Disorders Including substance abuse.	Not covered
Other Outpatient Expenses	Not covered
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, and Nurses	You pay 20% after deductible
Other Inpatient Services	You pay 20% after deductible

 

Prescription Drug Benefit	You Pay
Discount Card You may obtain Rx drugs at an average savings of 20-25%. Discounts vary by pharmacy, geographic area, and drug.	Discount card included, but prescriptions not covered under plan
Annual Maximum Covered expense, per person per calendar year.	Not applicable
READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!