March 21, 2010

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Health America – QHDHP 100% $2500 w/o HSA (includes Dental) – OHIO

A comparison of the QHDHP 100% $2500 w/o HSA (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 QHDHP 100% $2500 w/o HSA (includes Dental) Application QHDHP 100% $2500 w/o HSA (includes Dental) Application
Brochure QHDHP 100% $2500 w/o HSA (includes Dental) Brochure QHDHP 100% $2500 w/o HSA (includes Dental) Brochure
Copay Subject to deductible and coinsurance Subject to deductible and coinsurance
Office Visit 100% after deductible 50% after deductible
Deductible Individual: $2,500, Family: $5,000 Individual: $5,000, Family: $10,000
Coinsurance 100% after deductible 50% after deductible
Coinsurance Limit See OOP Maximum See OOP Maximum
Out-of-Pocket Maximum Individual: $4,000, Family: $8,000 Individual: $8,000, Family: $16,000
Lifetime Maximum QHDHP 100% $2500 w/o HSA (includes Dental) QHDHP 100% $2500 w/o HSA (includes Dental)
Prescription Drugs
  • Refer to the RX Select formulary to identify which drugs do not require authorization.
  • Quantity limits still apply.
  • Various riders available.
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
  • Refer to the RX Select formulary to identify which drugs do not require authorization.
  • Quantity limits still apply.
  • Various riders available.
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
    Emergency Room $150 Copay after deductible; ER Copay waived if admitted $150 Copay after deductible; ER Copay waived if admitted
    Adult Preventative Care
  • Gynecological Exam (PCP/SCP)- 100%
  • Adult Physical Visit- 100%
  • Routine Mammograms (Reimbursement limited to 130% if Medicare)- $30 Copay
  • Immunizations- 100%
    		•
  • 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)- 100%
  • Routine Pediatric Immunizations- 100%
  • Hearing Exams (under age 18)- 100%
    		•
  • 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 100% after deductible 50% after deductible
    Maternity Not Covered (except for complications) Not Covered (except for complications)
    Physical Therapy Occupational, Speech, Physical Therapy- 100% after deductible (45 inpatient days per contract year, 24 outpatient visits per contract year) Occupational, Speech, Physical Therapy- 50% after deductible (45 inpatient days per contract year, 24 outpatient visits per contract year)
    Skilled Nursing 100% after deductible, 50 days per contract year 50% after deductible, 50 days per contract year
    Home Health Care 100% after deductible, 120 visits per contract year 50% after deductible, 120 visits 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% after deductible
    • Physician Services (Outpatient)- 100% covered (Up to $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient, Transition Care)- 100% after deductible ($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 $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient, Transition Care)- 50% after deductible ($Up to $550 in eligible charges per contract year)
    		•
    Hospital Care 100% after deductible 50% after deductible
    Optional Benefits QHDHP 100% $2500 w/o HSA (includes Dental) QHDHP 100% $2500 w/o HSA (includes Dental)