March 17, 2010

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Coventry Health Care of Georgia – $20 Copay POS $10,000 Ded – GEORGIA

A comparison of the $20 Copay POS $10,000 Ded offered by Coventry Health Care of Georgia is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application $20 Copay POS $10,000 Ded Application $20 Copay POS $10,000 Ded Application
Brochure $20 Copay POS $10,000 Ded Brochure $20 Copay POS $10,000 Ded Brochure
Copay
  • Primary Care Physician Visits- $20
  • Specialist Visits- $55
    		•
  • Primary Care Physician Visits- 60% after deductible
  • Specialist Visits- 60% after deductible
    		•
    Office Visit
  • Primary Care Physician Visits- $20
  • Specialist Visits- $55
  • Includes lab and x-ray when performed in office.
    		•
  • Primary Care Physician Visits- 60% after deductible
  • Specialist Visits- 60% after deductible
    		•
    Deductible $10,000 Individual (3 Maximum per family) $20,000 Individual (3 Maximum per family)
    Coinsurance 70% after deductible 60% after deductible
    Coinsurance Limit Out-of-Pocket Max: $2,500 (3 Maximum per family) Out-of-Pocket Max: None
    Out-of-Pocket Maximum Out-of-Pocket Max: $2,500 (3 Maximum per family) Out-of-Pocket Max: None
    Lifetime Maximum $6,000,000 $6,000,000
    Prescription Drugs
  • $500 Deductible- Does Not Apply to Tier 1
  • Rx Deductible applies to Tier 2, Tier 3, & Tier 4 and must be satisfied before copays apply.
  • Retail (Must be obtained from Participating Pharmacies only except for Emergency):
    • Tier 1 (Preferred Generic)- $10 Copay - No Deductible
    • Tier 2 (Preferred Formulary Brand)- $35 Copay
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- $50 Copay
    • Tier 4 (Self- Administered Injectable Drugs)- $100 Copay
  • Mail Order - 93 day supply(Must be obtained from Caremark and Participating Pharmacies that offer Mail Order):
    • Tier 1 (Preferred Generic)- $10 Copay
    • Tier 2 (Preferred Formulary Brand)- $70 Copay
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- $150 Copay
    • Tier 4 (Self- Administered Injectable Drugs)- Not Covered
    		•
  • $500 Deductible- Does Not Apply to Tier 1
  • Rx Deductible applies to Tier 2, Tier 3, & Tier 4 and must be satisfied before copays apply.
  • Retail (Must be obtained from Participating Pharmacies only except for Emergency):
    • Tier 1 (Preferred Generic)- $10 Copay - No Deductible
    • Tier 2 (Preferred Formulary Brand)- $35 Copay
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- $50 Copay
    • Tier 4 (Self- Administered Injectable Drugs)- $100 Copay
  • Mail Order - 93 day supply(Must be obtained from Caremark and Participating Pharmacies that offer Mail Order):
    • Tier 1 (Preferred Generic)- $10 Copay
    • Tier 2 (Preferred Formulary Brand)- $70 Copay
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- $150 Copay
    • Tier 4 (Self- Administered Injectable Drugs)- Not Covered
    		•
    Emergency Room $150 Copay (waived if admitted to hospital) $150 Copay (waived if admitted to hospital)
    Adult Preventative Care
  • Preventive Screenings for Adults and Children (PCP & Specialist)- $20
  • Mammograms- Plan pays 100%
    		•
  • Preventive Screenings for Adults and Children (PCP & Specialist)- Not Covered
    		•
    Child Preventative Care
  • Preventive Screenings for Adults and Children (PCP & Specialist)- $20
    		•
  • Preventive Screenings for Adults and Children (PCP & Specialist)- Not Covered
    		•
    Lab / X-Ray Outpatient Hospital (X-ray, Lab, Diagnostic Services)- 70% after deductible Outpatient Hospital (X-ray, Lab, Diagnostic Services)- 60% after deductible
    Maternity Not Covered Not Covered
    Physical Therapy Short Term Therapies (Physical, Speech, Occupational, and Respiratory)- 70% after deductible, no visit limits Short Term Therapies (Physical, Speech, Occupational, and Respiratory)- 60% after deductible, no visit limits
    Skilled Nursing 70% after deductible (Limited to 30 days In- and Out-of-Network Combined) 60% after deductible (Limited to 30 days In- and Out-of-Network Combined)
    Home Health Care 70% after deductible (Limited to 30 days In- and Out-of-Network Combined) 60% after deductible (Limited to 30 days In- and Out-of-Network Combined)
    Mental Health Optional Mental Health Rider is available to be purchased Optional Mental Health Rider is available to be purchased
    Hospital Care 70% after deductible 60% after deductible
    Optional Benefits Mental Health Rider Mental Health Rider