March 18, 2010

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Consumers Life Company – Indiana Value 5000 – INDIANA

A comparison of the Indiana Value 5000 offered by Consumers Life Company is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Indiana Value 5000 Application Indiana Value 5000 Application
Brochure Indiana Value 5000 Brochure Indiana Value 5000 Brochure
Copay $35 $35
Office Visit $35 copay, then 100% 50% after deductible
Deductible $5,000 Individual/$15,000 Family $6,000 Individual/$18,000 Family
Coinsurance 70% 50%
Coinsurance Limit Indiana Value 5000 Indiana Value 5000
Out-of-Pocket Maximum Coinsurance Out-of-Pocket Maximum Individual: $4,000, Family: $12,000 (Excluding Deductible) Coinsurance Out-of-Pocket Maximum Individual: $25,000, Family: $50,000 (Excluding Deductible)
Lifetime Maximum $2,000,000 $2,000,000
Prescription Drugs
  • Prescription Drug Benefit Period Deductible- Individual: $250, Family: $500
  • Retail- 30 Day Supply, $15 Generic/$30 Formulary/50% with a minimum of $45 and maximum of $90 Non-Formulary
  • Home Delivery- 90 Day Supply, $37.50 Generic/$75 Formulary/$112.50 Non-Formulary
    		•
  • Prescription Drug Benefit Period Deductible- Individual: $250, Family: $500
  • Retail- 30 Day Supply, $15 Generic/$30 Formulary/50% with a minimum of $45 and maximum of $90 Non-Formulary
  • Home Delivery- 90 Day Supply, $37.50 Generic/$75 Formulary/$112.50 Non-Formulary
    		•
    Emergency Room
  • Emergency use: $250 copay, then 70% after deductible
  • Non-emergency use: Not Covered
    		•
  • Emergency use: $250 copay, then 70% after deductible
  • Non-emergency use: Not Covered
    		•
    Adult Preventative Care
  • Routine Physical Exam- Not Covered
  • Routine Mammogram (one per benefit period)- 70% after deductible
  • Routine Pap Test (one per benefit period)- 70% after deductible
    		•
  • Well Child Care services to age nine. Exams & Well Child Immunizations are limited to $1,000 per child to age 1; therafter, $150 per child per birth year to age 9
    • Office Visit- 50% after deductible
    • Immunizations & Labs- 50% after deductible
    • Child Preventative Care
  • Well Child Care services to age nine. Exams & Well Child Immunizations are limited to $1,000 per child to age 1; therafter, $150 per child per birth year to age 9
    • Office Visit- $35 copay, then 100%
    • Immunizations & Labs- 70% after deductible
    		•
  • Well Child Care services to age nine. Exams & Well Child Immunizations are limited to $1,000 per child to age 1; therafter, $150 per child per birth year to age 9
    • Office Visit- 50% after deductible
    • Immunizations & Labs- 50% after deductible
    • Lab / X-Ray Diagnostic Services- $250 copay per admission, then 70% after deductible Diagnostic Services- 50% after deductible
    Maternity Not Covered Not Covered
    Physical Therapy 10 visits per benefit period, 70% after deductible 10 visits per benefit period, 50% after deductible
    Skilled Nursing $10,000 maximum per benefit period, $250 copay per admission, then 70% after deductible $10,000 maximum per benefit period, 50% after deductible
    Home Health Care 60 visits per benefit period, 70% after deductible 60 visits per benefit period, 50% after deductible
    Mental Health Not Covered Not Covered
    Hospital Care 70% after deductible 50% after deductible
    Optional Benefits Indiana Value 5000 Indiana Value 5000