March 21, 2010

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Health America – QHDHP 80% $1200 w/o HSA (includes Dental) – PENNSYLVANIA

A comparison of the QHDHP 80% $1200 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 80% $1200 w/o HSA (includes Dental) Application QHDHP 80% $1200 w/o HSA (includes Dental) Application
Brochure QHDHP 80% $1200 w/o HSA (includes Dental) Brochure QHDHP 80% $1200 w/o HSA (includes Dental) Brochure
Copay N/A N/A
Office Visit 80% after deductible 50% after deductible
Deductible Individual: $1,200, Family: $2,400 Individual: $2,400, Family: $4,800
Coinsurance 80% after deductible 50% after deductible
Coinsurance Limit See OOP Maximum See OOP Maximum
Out-of-Pocket Maximum Individual: $5,000, Family: $10,000 Unlimited
Lifetime Maximum QHDHP 80% $1200 w/o HSA (includes Dental) QHDHP 80% $1200 w/o HSA (includes Dental)
Prescription Drugs
  • $10 Generic Copay/$30 Brand Copay/$50 Non-Formulary Copay (after annual deductible)
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
  • $10 Generic Copay/$30 Brand Copay/$50 Non-Formulary Copay (after annual deductible)
  • Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply.
    		•
    Emergency Room 80% after deductible 80% after deductible
    Adult Preventative Care
  • Gynecological Exam (PCP/SCP)- 80%
  • Adult Physical Visit- 80%
  • 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 10)- 50% after deductible
    		•
    Child Preventative Care
  • Well Child Visit (up to age 9, no deductible)- 80%
  • Routine Pediatric Immunizations- 80%
  • Hearing Exams (under age 10)- 80% after deductible
    		•
  • Well Child Visit (up to age 9, no deductible)- 50%
  • Routine Pediatric Immunizations- 50%
  • Hearing Exams (under age 10)- 50% after deductible
    		•
    Lab / X-Ray 80% after deductible 50% after deductible
    Maternity Not Covered (except for complications) Not Covered (except for complications)
    Physical Therapy Occupational, Speech, Physical Therapy- Subject to deductible and coinsurance (45 inpatient days per contract year, 24 outpatient visits per contract year) Occupational, Speech, Physical Therapy- 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 visits per contract year Subject to deductible and coinsurance, 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- 80% after deductible
    • Physician Services (Outpatient)- 80% after deductible (Up to $550 in eligible charges per contract year)
    • Substance Abuse (Inpatient, Outpatient, Transition Care)- 80% after deductible ($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 Subject to deductible and coinsurance Subject to deductible and coinsurance
    Optional Benefits QHDHP 80% $1200 w/o HSA (includes Dental) QHDHP 80% $1200 w/o HSA (includes Dental)