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American Medical Security Life Insurance Company – MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% – INDIANA
A comparison of the MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% offered by American Medical Security Life Insurance Company is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
||
| Network | See Provider | See Provider |
| Application | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% Application | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% Application |
| Brochure | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% Brochure | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% Brochure |
| Copay | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% |
| Office Visit | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | Subject to deductible, then coinsurance. |
| Deductible | $2,500(2 per family maximum) | $5,000(2 per family maximum) |
| Coinsurance | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% |
| Coinsurance Limit | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% |
| Out-of-Pocket Maximum | $4,500 per person | $9,000 per person |
| Lifetime Maximum | $5,000,000 | $5,000,000 |
| Prescription Drugs | ||
| Emergency Room | $100 copay then subject to deductible, then coinsurance.(Copay is waived if immediately confined) | $100 copay then subject to deductible, then coinsurance.(Copay is waived if immediately confined) |
| Adult Preventative Care | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | Not Covered |
| Child Preventative Care | MedOne Plus- PPO Benefit Plan w/Rx Opt $0/$15/50% | Not Covered |
| Lab / X-Ray | Subject to deductible, then coinsurance. | Subject to deductible, then coinsurance. |
| Maternity | Not covered | Not covered |
| Physical Therapy | Subject to deductible, then coinsurance. | Subject to deductible, then coinsurance. |
| Skilled Nursing | Subject to deductible, then coinsurance. Limited to 30 days per calendar year. | Subject to deductible, then coinsurance. Limited to 30 days per calendar year. |
| Home Health Care | Subject to deductible, then coinsurance. Limited to 20 visits per calendar year. | Subject to deductible, then coinsurance. Limited to 20 visits per calendar year. |
| Mental Health | Not covered | Not covered |
| Hospital Care | Subject to deductible, then coinsurance. | Subject to deductible, then coinsurance. |
| Optional Benefits | XL Option |
XL Option |