March 20, 2010

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Health America – Copay 100% $0 (includes Dental) – PENNSYLVANIA

A comparison of the Copay 100% $0 (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 Copay 100% $0 (includes Dental) Application Copay 100% $0 (includes Dental) Application
Brochure Copay 100% $0 (includes Dental) Brochure Copay 100% $0 (includes Dental) Brochure
Copay Primary Care Visit- $20 Copay, Specialist Visit- $40 Copay 50% after deductible
Office Visit Primary Care Visit- $20 Copay, Specialist Visit- $40 Copay 50% after deductible
Deductible None $5,000 Individual, $10,000 Family
Coinsurance 100% after deductible 50% after deductible
Coinsurance Limit Copay 100% $0 (includes Dental) Copay 100% $0 (includes Dental)
Out-of-Pocket Maximum Unlimited $5,000 Individual, $10,000 Family
Lifetime Maximum $5,000,000 $5,000,000
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 (waived if admitted and then inpatient copay applies) $200 copay (waived if admitted and then inpatient copay applies)
    Adult Preventative Care
  • Gynecological Exam (PCP/SCP)- $20/$40 Copay
  • Adult Physical Visit- $20 Copay
  • Routine Mammograms- 100%
    		•
  • Well Child Visit (Up to age 9, no deductible)- 50% after deductible
  • Routine Pediatric Immunizations- 50%
  • Hearing Exams (under age 10)- 50% after deductible
    		•
    Child Preventative Care
  • Well Child Visit (Up to age 9, no deductible)- $20 Copay
  • Routine Pediatric Immunizations- 100%
  • Hearing Exams (under age 10)- 100%
    		•
  • Well Child Visit (Up to age 9, no deductible)- 50% after deductible
  • Routine Pediatric Immunizations- 50%
  • Hearing Exams (under age 10)- 50% after deductible
    		•
    Lab / X-Ray Lab Services- 100%, Diagnostic X-ray- $40 Lab Services- 50% after deductible, Diagnostic X-ray- 50% after deductible
    Maternity Not Covered (except for complications) Not Covered (except for complications)
    Physical Therapy 100% ($200/day; 5 day maximum, 45 inpatient days per contract year, 24 outpatient visits per contract year) 50% after deductible (45 inpatient, 24 outpatient visits per contract year)
    Skilled Nursing 100% ($200/day; 5 day maximum), 50 days per contract year> 50% after deductible, 50 days per contract year
    Home Health Care 100%, 120 visits per contract year 50%, 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% ($200/day; 5 day maximum)
    • Physician Services (Outpatient)- $40 Copay (Up to $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient and Transition Care)- $40 Copay (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 100% ($200/day; 5 day maximum) 50% after deductible
    Optional Benefits Copay 100% $0 (includes Dental) Copay 100% $0 (includes Dental)