Imerica - Healthy America – PPO Platinum Series with 12 Month Rate Guarantee, Lifetime Max $5 Million – South Carolina

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

• Compare to other Imerica - Healthy America plans.

• Compare to all carriers in South Carolina.

	Network	Non-Network
Network	See Provider	See Provider
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	4 Visits- $15 Primary Care Physician/$60 Specialist	4 Visits- $15 Primary Care Physician/$60 Specialist
Office Visit	Subject to copay	Subject to copay
Deductible	$1,500(Maximum of 3 per family)	$2,000 per person in addition to in-network deductible
Coinsurance	80%	60%
Coinsurance Limit	$10,000	$10,000
Out-of-Pocket Maximum	$2,000 plus deductible	$8,000 plus deductible
Lifetime Maximum	$5 Million	$5 Million
Prescription Drugs	Generic: $0 deductible w/$15 copay Brand: $500 deductible w/$40 copay	Generic: $0 deductible w/$15 copay Brand: $500 deductible w/$40 copay
Emergency Room	Deductible and Coinsurance	Deductible and Coinsurance
Adult Preventative Care	see brochure	see brochure
Child Preventative Care	see brochure	see brochure
Lab / X-Ray	see brochure	see brochure
Maternity	see brochure	see brochure
Physical Therapy	see brochure	see brochure
Skilled Nursing	see brochure	see brochure
Home Health Care	see brochure	see brochure
Mental Health	see brochure	see brochure
Hospital Care	Deductible and Coinsurance	Deductible and Coinsurance
Optional Benefits	Life Maternity SAE (CIB Only)	Life Maternity SAE (CIB Only)