March 12, 2010

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Imerica – PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million – MISSOURI

A comparison of the PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million offered by Imerica is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Application PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million Application PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million Application
Brochure PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million Brochure PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million Brochure
Copay Physician Office Visit (Office co-pay rider included: 4 visits maximum; After 4 visits deductible and co-insurance apply):
  • Primary care physician: $15
  • Specialist: $60
 Physician Office Visit (Office co-pay rider included: 4 visits maximum; After 4 visits deductible and co-insurance apply):
  • Primary care physician: $15
  • Specialist: $60
Office Visit Physician Office Visit (Office co-pay rider included: 4 visits maximum; After 4 visits deductible and co-insurance apply):
  • Primary care physician: $15
  • Specialist: $60
 Physician Office Visit (Office co-pay rider included: 4 visits maximum; After 4 visits deductible and co-insurance apply):
  • Primary care physician: $15
  • Specialist: $60
Deductible $5,000(Maximum of 3 per family) $2,000 per person in addition to in-network deductible
Coinsurance 80% 60%
Coinsurance Limit PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Out-of-Pocket Maximum Individual: $2,000, Family: 3 times deductible plus 3 times coinsurance Individual: $8,000, Family: 3 times deductible plus 3 times coinsurance
Lifetime Maximum $2 Million Base, Optional Buyup $5 Million or $8 Million $2 Million Base, Optional Buyup $5 Million or $8 Million
Prescription Drugs Pharmacy:
  • Generic: $0 deductible with $15 co-pay
  • Brand: $500 deductible with $40 co-pay
 Pharmacy:
  • Generic: $0 deductible with $15 co-pay
  • Brand: $500 deductible with $40 co-pay
Emergency Room Subject to deductible and coinsurance Subject to deductible and coinsurance
Adult Preventative Care Wellness Benefits (subject to co-insurance only):
  • Routine Physical Exams: Up to $500, no waiting period
  • Preventive (No maximum, no waiting period): Mammograms, PAP test screening, childhood immunizations, prostate cancer screening, colorectal cancer screening
 Wellness Benefits (subject to co-insurance only):
  • Routine Physical Exams: Up to $500, no waiting period
  • Childhood immunizations: No maximum, no waiting period
Child Preventative Care Wellness Benefits (subject to co-insurance only):
  • Routine Physical Exams: Up to $500, no waiting period
  • Childhood immunizations: No maximum, no waiting period
 Wellness Benefits (subject to co-insurance only):
  • Routine Physical Exams: Up to $500, no waiting period
  • Childhood immunizations: No maximum, no waiting period
Lab / X-Ray PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Maternity PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Physical Therapy PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Skilled Nursing PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Home Health Care PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Mental Health PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million
Hospital Care Subject to deductible and coinsurance Subject to deductible and coinsurance
Optional Benefits PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million