Gold 201 HSA
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Customer Reviews: Not Yet Rated
Plan Summary | |
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Plan Type | EPO |
Office Visit for Primary Doctor
|
No Charge after deductible |
Office Visit for Specialist | No Charge after deductible |
Office Visit for Other Practitioner (Nurse, Physician Assistant) | No Charge after deductible |
Annual Deductible | Individual: $3,300 |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Coinsurance | 0% |
Retail Prescription Drugs | Generic Drugs: No Charge after deductible; Preferred Brand Drugs: No Charge after deductible; Non-Preferred Brand Drugs: No Charge after deductible; Specialty Drugs: No Charge after deductible; |
Annual Out-of-Pocket Limit | Individual: $3,300 Includes deductible |
Lifetime Maximum | Unlimited |
Health Savings Account (HSA) Eligible | No |
Out-of-Network Coverage | No |
Out-of-Country Coverage | No. |
Office Visit | |
Primary Care Physician Required | Yes |
Specialist Referrals Required | No |
Preventive Care Coverage | |
Periodic Health Exam | No Charge |
Periodic OB-GYN Exam | No Charge |
Well Baby Care | No Charge |
Emergency and Urgent Care | |
Emergency Room | No Charge after deductible |
Emergency Ambulance Services | No Charge after deductible |
Urgent Care Facility | No Charge after deductible |
Prescription Drug Coverage | |
Retail Prescription Drugs | Generic Drugs: No Charge after deductible; Preferred Brand Drugs: No Charge after deductible; Non-Preferred Brand Drugs: No Charge after deductible; Specialty Drugs: No Charge after deductible; |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Mail Order Prescription Drugs | N/A |
Mail Order Supply | N/A |
Outpatient Coverage | |
Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: No Charge after deductible Outpatient Facility Fee: No Charge after deductible |
Outpatient Lab/X-Ray | Outpatient Lab: No Charge after deductible X-rays: No Charge after deductible |
Imaging (CT and PET scans, MRIs) | No Charge after deductible |
Outpatient Mental Health | No Charge after deductible |
Outpatient Substance Abuse | No Charge after deductible |
Outpatient Rehabilitation Services (PT, OT, ST) | No Charge after deductible, limited to 20 Visit(s) per Year |
Inpatient Coverage | |
Hospitalization | Inpatient Hospital Services: No Charge after deductible Inpatient Physician and Surgical Services: No Charge after deductible |
Skilled Nursing Facility | No Charge after deductible, limited to 60 Days per Year |
Inpatient Mental Health | No Charge after deductible |
Inpatient Substance Abuse | No Charge after deductible |
Home Healthcare | No Charge after deductible, limited to 60 Visit(s) per Year |
Maternity Coverage | |
Pre & Postnatal Office Visit | No Charge after deductible |
Labor & Delivery Hospital Stay | No Charge after deductible |
Pediatric Services | |
Dental Checkup for Children | Not Covered |
Vision Screening for Children | No Charge, limited to 1 Exam(s) per Year |
Eye Glasses for Children | No Charge, limited to 1 Item(s) per Benefit Period |
Major Dental Coverage (Pediatric) | Not Covered |
Additional Coverage | |
Chiropractic Coverage | No Charge after deductible, limited to 20 Visit(s) per Year |
Durable Medical Equipment | No Charge after deductible |
Hospice | No Charge after deductible |
Major Dental Coverage (Adult) | Not Covered |
Vision Coverage (Adult) | Not Covered |
Out-of-Network Coverage | |
Out-of-Network Authorization Required | N/A |
Out-of-Network Annual Deductible | N/A |
Out-of-Network Annual Coinsurance | N/A |
Out-of-Network Annual Out-of-Pocket Limit | N/A |
Additional Information | |
A.M. Best Rating | N/A as of 11/10/2024 |
Electronic Signature for Application Available | Yes |
Details and documents about this plan | |
View Plan Brochure Exclusions and Limitations |
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
- The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.