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Deluxe 5000
Plan Summary
Plan Type Indemnity
Office Visit for Primary Doctor
Find Doctors 		$30 copay; max 3 visits for any office appointment per coverage period. General Practitioner doctor, specialty doctor and Urgent Care visits have a combined 3 visit maximum. Additional visits are subject to deductible and coinsurance.
Office Visit for Specialist $60 copay; max 3 visits for any office appointment per coverage period. General Practitioner doctor, specialty doctor and Urgent Care visits have a combined 3 visit maximum. Additional visits are subject to deductible and coinsurance.
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $5,000
Separate Prescription Drugs Deductible None
Coinsurance 20% coinsurance after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $8,000
Includes deductible
Includes Coinsurance, Deductible and Copayments
Lifetime Maximum $1 Million per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required N/A
Specialist Referrals Required N/A
Preventive Care Coverage
Periodic Health Exam 100% of Eligible Expenses not to exceed $200 per coverage period
Periodic OB-GYN Exam 20% coinsurance after deductible
Well Baby Care 20% coinsurance after deductible (Immunizations are not subject to deductible)
Emergency and Urgent Care
Emergency Room 20% Coinsurance after deductible; Extra $250 deductible applies if not admitted.
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs N/A
Mail Order Supply Not Covered
Outpatient Coverage
Outpatient Surgery 20% coinsurance after deductible
Outpatient Lab/X-Ray 20% coinsurance after deductible
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 20% coinsurance after deductible; Extended care facility up to $150 a day for a maximum of 60 days
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit N/A
Labor & Delivery Hospital Stay N/A
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
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 A+ as of 12/20/2023
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • 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.