March 15, 2010

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Avalon Healthcare – IFOCUS Plan A-6 D, RxA – FLORIDA

A comparison of the IFOCUS Plan A-6 D, RxA offered by Avalon Healthcare is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application IFOCUS Plan A-6 D, RxA Application IFOCUS Plan A-6 D, RxA Application
Brochure IFOCUS Plan A-6 D, RxA Brochure IFOCUS Plan A-6 D, RxA Brochure
Copay
  • PCP: $25 Copay, then covered at 100%
  • Specialist: $50 Copay, then covered at 100%
    		•
  • PCP: Deductible & Coinsurance
  • Specialist: Deductible & Coinsurance
    		•
    Office Visit
  • PCP: $25 Copay, then covered at 100%
  • Specialist: $50 Copay, then covered at 100%
    		•
  • PCP: Deductible & Coinsurance
  • Specialist: Deductible & Coinsurance
    		•
    Deductible
  • Individual: $2,000, Family: $4,000
    		•
  • Individual: $4,000, Family: $8,000
    		•
    Coinsurance 100% 80%
    Coinsurance Limit
  • Individual: $0, Family: $0
    		•
  • Individual: $4,000, Family: $8,000
    		•
    Out-of-Pocket Maximum
  • Individual: $2,000, Family: $4,000
    		•
  • Individual: $8,000, Family: $16,000
    		•
    Lifetime Maximum $5,000,000 (Maximum applies to combined in and out of network benefits). $5,000,000 (Maximum applies to combined in and out of network benefits).
    Prescription Drugs
  • $0 deductible
  • Retail Generic/Formulary/Non-Formulary- $10/$30/$50
  • Mail Order 90-Day Supply- 2.5 x Retail
    		•
  • $0 deductible, then 50% Coinsurance
    		•
    Emergency Room Deductible & Coinsurance Deductible & Coinsurance
    Adult Preventative Care
  • Annual Routine Ob/Gyn Exam (Annual Pap/Mammogram): $25 Copay.
  • Preventive Health (Physical, waiting period waived): $25 Copay.
  • Deductible waived for all
    		•
  • Well Child Care, incl. Immunizations (to age 16 per guidelines)- Coinsurance only - deductible waived
    		•
    Child Preventative Care
  • Well Child Care, incl. Immunizations (to age 16 per guidelines)- $25 Copay, then covered at 100%
    		•
  • Well Child Care, incl. Immunizations (to age 16 per guidelines)- Coinsurance only - deductible waived
    		•
    Lab / X-Ray Deductible & Coinsurance Deductible & Coinsurance
    Maternity See Optional Rider See Optional Rider
    Physical Therapy
  • Deductible & Coinsurance (prior authorization required; limited to 60 visits/year)
    		•
  • Deductible & Coinsurance (prior authorization required; limited to 60 visits/year)
    		•
    Skilled Nursing
  • Deductible & Coinsurance (prior authorization required; limited to 30 days/year)
    		•
  • Deductible & Coinsurance (prior authorization required; limited to 30 days/year)
    		•
    Home Health Care
  • Deductible & Coinsurance (prior authorization required; limited to 30 visits/year)
    		•
  • Deductible & Coinsurance (prior authorization required; limited to 30 visits/year)
    		•
    Mental Health Not Applicable Not Applicable
    Hospital Care Deductible & Coinsurance Deductible & Coinsurance
    Optional Benefits None None