March 19, 2010

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Health America – Deductible 100% $5000 (includes Dental) – OHIO

A comparison of the Deductible 100% $5000 (includes Dental) offered by Health America is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Deductible 100% $5000 (includes Dental) Application Deductible 100% $5000 (includes Dental) Application
Brochure Deductible 100% $5000 (includes Dental) Brochure Deductible 100% $5000 (includes Dental) Brochure
Copay N/A N/A
Office Visit Subject to deductible and coinsurance Subject to deductible and coinsurance
Deductible Individual: $5,000, Family: $10,000 Individual: $10,000, Family: $20,000
Coinsurance 100% after deductible 50% after deductible
Coinsurance Limit See OOP Maximum See OOP Maximum
Out-of-Pocket Maximum Individual: $5,000, Family: $10,000 Individual: $10,000, Family: $20,000
Lifetime Maximum Deductible 100% $5000 (includes Dental) Deductible 100% $5000 (includes Dental)
Prescription Drugs
  • $100 single/$300 family deductible (deductible applies to Tier 2 and Tier 3 only)
  • $15 Tier 1 Copay (Generic)/$25 Tier 2 Copay (Brand Name)/$50 Tier 3 Copay (Non-Formulary)
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
  • $100 single/$300 family deductible (deductible applies to Tier 2 and Tier 3 only)
  • $15 Tier 1 Copay (Generic)/$25 Tier 2 Copay (Brand Name)/$50 Tier 3 Copay (Non-Formulary)
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
    Emergency Room $200 copay after deductible $200 copay after deductible
    Adult Preventative Care
  • Gynecological Exam (PCP/SCP)- 90%
  • Adult Physical Visit- 90%
  • Routine Mammograms (Reimbursement limited to 130% if Medicare)- $30 Copay
    		•
  • Well Child Visit (up to age 9, no deductible)- 50%
  • Routine Pediatric Immunizations- 50%
  • Hearing Exams (under age 18)- 50% after deductible
    		•
    Child Preventative Care
  • Well Child Visit (up to age 9, no deductible)- 90%
  • Routine Pediatric Immunizations- 90%
  • Hearing Exams (under age 18)- 90%
    		•
  • Well Child Visit (up to age 9, no deductible)- 50%
  • Routine Pediatric Immunizations- 50%
  • Hearing Exams (under age 18)- 50% after deductible
    		•
    Lab / X-Ray Subject to deductible and coinsurance Subject to deductible and coinsurance
    Maternity Not Covered (except for complications) Not Covered (except for complications)
    Physical Therapy Subject to deductible and coinsurance (45 inpatient days per contract year, 24 outpatient visits per contract year) Subject to deductible and coinsurance (45 inpatient days per contract year, 24 outpatient visits per contract year)
    Skilled Nursing Subject to deductible and coinsurance, 50 days per contract year Subject to deductible and coinsurance, 50 days per contract year
    Home Health Care Subject to deductible and coinsurance, 120 days per contract year Subject to deductible and coinsurance, 120 days per contract year
    Mental Health
  • General Mental Illness:
    • Inpatient- Not Covered
    • Physician Services (Outpatient)- 10 visits per contract year
  • Biologically Based Mental Illness:
    • Inpatient- 100%
    • Physician Services (Outpatient)- 100% after deductible (Up to $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient and Transition Care)- 100% after deductible (Up to $550 in eligible charges per contract year)
    		•
  • General Mental Illness:
    • Inpatient- Not Covered
    • Physician Services (Outpatient)- 10 visits per contract year
  • Biologically Based Mental Illness:
    • Inpatient- 50% after deductible
    • Physician Services (Outpatient)- 50% after deductible (Up to $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient and Transition Care)- 50% after deductible (Up to $550 in eligible charges per contract year)
    		•
    Hospital Care Subject to deductible and coinsurance Subject to deductible and coinsurance
    Optional Benefits Deductible 100% $5000 (includes Dental) Deductible 100% $5000 (includes Dental)