March 16, 2010

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Coventry Health Care of Georgia – Qualified High Deductible HP POS $5,000 / $10,000 Ded – GEORGIA

A comparison of the Qualified High Deductible HP POS $5,000 / $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 Qualified High Deductible HP POS $5,000 / $10,000 Ded Application Qualified High Deductible HP POS $5,000 / $10,000 Ded Application
Brochure Qualified High Deductible HP POS $5,000 / $10,000 Ded Brochure Qualified High Deductible HP POS $5,000 / $10,000 Ded Brochure
Copay
  • Preventive Screenings for Adults and Children (PCP & Specialist)- $20
    		•  Not Covered
    Office Visit
  • Primary Care Physician Visits- 100% after deductible
  • Specialist Visits- 100% after deductible
  • Includes lab and x-ray when performed in office
    		•
  • Primary Care Physician Visits- 60% after deductible
  • Specialist Visits- 60% after deductible
    		•
    Deductible $5,000 (Family $10,000) $10,000 (Family $20,000)
    Coinsurance 100% after deductible 60% after deductible
    Coinsurance Limit Out-of-Pocket Max: $5,000 Out-of-Pocket Max: $10,000
    Out-of-Pocket Maximum Out-of-Pocket Max: $5,000 Out-of-Pocket Max: $10,000
    Lifetime Maximum $6,000,000 $6,000,000
    Prescription Drugs
  • Subject to plan deductible
  • Retail (Must be obtained from Participating Pharmacies only except for Emergency):
    • Tier 1 (Preferred Generic)- Covered 100% after deductible.
    • Tier 2 (Preferred Formulary Brand)- Covered 100% after deductible.
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- Covered 100% after deductible.
    • Tier 4 (Self- Administered Injectable Drugs)- Covered 100% after deductible.
  • Mail Order - 93 day supply(Must be obtained from Caremark and Participating Pharmacies that offer Mail Order):
    • Tier 1 (Preferred Generic)- Covered 100% after deductible.
    • Tier 2 (Preferred Formulary Brand)- Covered 100% after deductible.
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- Covered 100% after deductible.
    • Tier 4 (Self- Administered Injectable Drugs)- Not Covered
    		•
  • Subject to plan deductible
  • Retail (Must be obtained from Participating Pharmacies only except for Emergency):
    • Tier 1 (Preferred Generic)- Covered 100% after deductible.
    • Tier 2 (Preferred Formulary Brand)- Covered 100% after deductible.
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- Covered 100% after deductible.
    • Tier 4 (Self- Administered Injectable Drugs)- Covered 100% after deductible.
  • Mail Order - 93 day supply(Must be obtained from Caremark and Participating Pharmacies that offer Mail Order):
    • Tier 1 (Preferred Generic)- Covered 100% after deductible.
    • Tier 2 (Preferred Formulary Brand)- Covered 100% after deductible.
    • Tier 3 (Non Preferred Brand and a few Non Preferred Generic)- Covered 100% after deductible.
    • Tier 4 (Self- Administered Injectable Drugs)- Not Covered
    		•
    Emergency Room 100% after deductible 60% after deductible
    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)- 100% 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)- 100% after deductible, no visit limits Short Term Therapies (Physical, Speech, Occupational, and Respiratory)- 60% after deductible, no visit limits
    Skilled Nursing 100% 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 100% 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 Covered - Qualified High Deductible HP POS $5,000 / $10,000 Ded Covered - Qualified High Deductible HP POS $5,000 / $10,000 Ded
    Hospital Care 100% after deductible 60% after deductible
    Optional Benefits None None