Participating MEMBER RESPONSIBILITY
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1 DEDUCTIBLES AND MAXIMUMS Non- Annual Deductible Individual $2,000 $4,000 Family $4,000 $8,000 Out-of-Pocket Maximum (includes deductible, coinsurance, and copays) Individual Unlimited $10,000 Family Unlimited $20,000 OUTPATIENT SERVICES Non- Physician Services (for illness or injury) Level One Visits (PCP, OBGYN, Dermatologists, Chiropractors) $20 Copay 30% Eligible Charges (after annual deductible) Level Two Visits (all other office visits) $40 Copay (after annual deductible) 30% Eligible Charges (after annual deductible) Preventive Services* Gynecological Exam (PCP/SCP) $0 Copay 30% Eligible Charges (after annual deductible) Well Child Visit (up to age 9, no deductible) $0 Copay 30% Eligible Charges Adult Physical Visit $0 Copay 30% Eligible Charges (after annual deductible) Preventive Pediatric Immunizations 0% 30% Eligible Charges Hearing Exams (under age 18) 0% 30% Eligible Charges (after annual deductible) Routine Mammograms 0% $30 Copay Routine Colonscopies 0% 30% Eligible Charges (after annual deductible) Allergy Testing & Injection (Serum not covered) 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Chiropractic Care Maximum 20 visits per contract year $20 Copay 30% Eligible Charges (after annual deductible) Outpatient Surgery 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Lab Services 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Diagnostic X-ray 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Radiology (CAT, MRI, Ultrasound) $200 (after annual deductible) 30% Eligible Charges (after annual deductible) HOSPITAL SERVICES Non- Hospital Care Semi-private room (private room if medically necessary) 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Physician and Surgeon Fees 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Surgery 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Lab and X-ray services 0% (after annual deductible) 30% Eligible Charges (after annual deductible) All Medically Necessary Ancillary Services 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Anesthesia 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Administration of Blood 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Blood Products 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Therapy Services (Chemotherapy & Radiation Therapy) 0% (after annual deductible) 30% Eligible Charges (after annual deductible) MATERNITY SERVICES Non- Pregnancy Care & Delivery 9 month waiting period for all covered maternity svcs Inpatient Care Copayment (hospital services) $2500 Copay (per admission) not subject to deductible 30% Eligible Charges (after annual deductible) Prenatal Visits $20 Copay (first visit only) not subject to deductible 30% Eligible Charges (after annual deductible) Other maternity services (includes diagnostic tests, delivery and other physician services) 0% (after annual deductible) 30% Eligible Charges (after annual deductible) FAMILY PLANNING Infertility Counseling/Testing/Services Tubal Ligation/Vasectomy PRESCRIPTION DRUGS (Includes oral contraceptives & managed formulary. Mandatory generic substitution may apply) Preferred Provider Organization Underwritten by Health Assurance Pennsylvania, Inc. Choice1 PPO $2000 Not Covered $15 Tier 1 $35 Tier 2 (after annual deductible) $60 Tier 3 (after annual deductible) *refer to Rx Select Formulary Non- Non- EMERGENCY CARE Non- Urgent Care Center $40 Copay (after annual deductible) Emergency Room Services $200 Copay (after annual deductible) ER Copay waived if admitted REHABILITATION SERVICES Non- Occupational, Speech, Physical Therapy 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 45 inpatient days per contract year 24 outpatient visits per contract year Choice1 PPO $ (95149).doc 6/19/2012
2 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES General Mental Health: Inpatient Not Covered Non- Physician Services (Outpatient) $40 Copay (after annual deductible) 30% Eligible Charges (after annual deductible) 10 visits per contract year Biologically Based Mental Illness: Inpatient 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Physician Services (Outpatient) $40 Copay (after annual deductible) 30% Eligible Charges (after annual deductible) Substance Abuse: Inpatient Detoxification 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 7 days maximum per admission 4 admission benefit maximum Inpatient Rehabilitation 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 30 days maximum per contract year 90 days benefit maximum Transitional Partial Hospitalization 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 60 visits per contract year 120 visits per benefit maximum 30 outpatient visits may be exchanged on a two-for-one basis for up to 15 additional non-hospital residential or inpatient treatment days OTHER BENEFITS Non- Claim Forms Required No Yes Durable Medical Equipment (DME) Limited to once every 2 years for irreparable damage and/or normal wear. 30% (after annual deductible) 30% Eligible Charges (after annual deductible) Corrective Appliances 30% (after annual deductible) 30% Eligible Charges (after annual deductible) Home Health Care Services 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 120 visits combined per contract year Hospice Care 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Skilled Nursing Facility 0% (after annual deductible) 30% Eligible Charges (after annual deductible) 50 days combined maximum per contract year Dental Services Emergency treatment of dental injury 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Removal of Third Molars 0% (after annual deductible) 30% Eligible Charges (after annual deductible) Vision Services Vision One Eyecare Program : Receive immediate savings on all eyecare needs--discounts on frames, lenses, disposable contacts, and even LASIK surgery--at participating providers through the EyeMed Vision Care network. Health Education Members receive reimbursement of the cost of approved wellness programs offered through local hospitals and organizations.** PRECERTIFICATION REQUIREMENT By Physician By Patient When using a nonparticipating provider, the member must obtain precertification of nonemergency hospital and other facility (e.g., skilled nursing facilities, rehabilitation facilities, drug and alcohol treatment facilities) admissions, outpatient surgery and certain other services as stated in the Group Contract. If these services or admissions are not precertified, and the service is not medically necessary, the member may be responsible for 100% of the cost of the services. LIFETIME MAXIMUM Unlimited This is not a contract. It is intended solely to provide you with an overview of the plan. Complete details of benefits, terms and exclusions are governed by your Group Contract. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call us at in Central/Eastern Pennsylvania, and in Western Pennsylvania and Ohio. Benefits are administered on a contract year basis. Coinsurance is based on Eligible Charges as defined in your Certificate of Insurance. For non-participating providers, Eligible Charges are based on the lesser of the provider's billed charges or our Out-of-Network Rate, which is defined in your Certificate of Insurance. In addition to your copay or coinsurance, you are responsible for paying nonparticipating providers the difference between our out-of-network rate and their actual charge for nonemergency services. Your out-of-pocket costs for nonemergency care from nonparticipating providers may be substantial. ** Reimbursement for Weight Management programs is limited to $350 per calendar year per member. Dependent Coverage Age Limit is up to 26 Choice1 PPO $ (95149).doc 6/19/2012
3 Dental Choice. Simplicity. Affordability. The following basic, preventive, & diagnostic services are covered at any licensed dentist. Preventive & Diagnostic (covered procedure code) In Network Out of Network** Benefit Guidelines Periodic Oral Evaluation (0120) 100% 100%** One per year Comprehensive Oral Evaluation (0150) 100% 100%** One evaluation w/ new dentist Bitewing X-rays (0272) 100% 100%** Once per 12 months; one set Cleaning (Prophylaxis) Adult (1110) 100% 100%** One per year Cleaning (Prophylaxis) Child (1120) 100% 100%** One per year Basic Services Amalgam Filling (2140, 2150, 2160) 100% 100%** One per year Resin-based Filling (2330,2331, 2332) 100% 100%** One per year Plan Description Deductible $0 $0 Annual Maximum $300 $300 Reimbursement MAC* MAC* Waiting Periods No No Find a network provider at Questions? Call Customer Service at or visit us on the web at Notes: Procedures not listed are excluded from coverage under your insurance benefit; however, network providers may offer you a discounted price on noncovered services. *Maximum allowable charge for network providers accepting our fees. **Non-network providers are reimbursed at the maximum allowable charge and may charge members the difference between the billed amount and the reimbursed amount. This brochure is not a contract. It is intended solely to provide you with a general overview of our health insurance products. Complete details of benefits, terms, and exclusions that apply to your health care coverage are governed by the group contract between Coventry Health and Life Insurance Company and the HealthAmerica Ohio Insurance Trust and the Trust Participation Agreement between you and HealthAmerica. HealthAmericaOne is offered through the HealthAmerica Ohio Insurance Trust. HealthAmericaOne products are underwritten by Coventry Health and Life Insurance Company (d.b.a. HealthAmerica). 4/03/12 HAH HealthAmerica
4 Our Vision Discount Program Puts The Numbers In Your Favor EyeMed Vision Care contracts with optometrists and ophthalmologists to perform comprehensive eye exams. Providers are located near you and offer convenient hours to fit your schedule. Millions are diagnosed annually with vision problems. HealthAmerica understands that proper vision care is extremely impor tant. That s why we offer our members a value-added vision discount program through The Vision One Eyecare Program. It offers immediate savings on your eye care needs including eye exams, eyeglass frames, and lenses.* Thousands of providers make it convenient for you. National network locations include LensCrafters, Sears Optical, Target Optical, participating Pearle Vision locations, JCPenney Optical, and select independent doctors of optometry. Visit our website at for a list of participating providers, or call EyeMed Vision Care at Zero hassles make it easy to get care. Simply present your HealthAmerica or HealthAssurance ID card to any EyeMed network provider to access plan # and receive discounts on eyeglass lenses, frames, conventional lenses, and additional purchases such as tinting and UV coating. Other program features include: Mail Order contact lens program. LASIK discount program. Call LASER6 for details. No claim forms! Use your discount as often as you want. * Vision One Eyecare discounts cannot be used with vision benefits, in-store promotions or other discounts. If you have health coverage through your employer, be sure to check with your benefits administrator for any additional benefits or discounts. S E E OT H E R S I D E F O R M O R E I N F O R M AT I O N
5 Vision One Eyecare Program Hundreds of dollars can be saved when you visit EyeMed Vision Care providers. Examinations The cost of a routine eye examination is $ Additional fees apply for contact lens examinations *. TYPICAL Lenses (standard uncoated plastic) COST COST Single Vision $120 $50 Bifocal $185 $70 Trifocal $210 $105 Other Eye Care Needs PARTICIPANT Members and their families also can save up to: 40% on frames 20% on selected accessories 35% on lenses 15% on conventional contact lenses 20% on specialty lenses To find an EyeMed provider near you, visit our website at When using the online provider search, be sure to enter your zip code and choose "Select" as your network. You can also call EyeMed Vision Care at to find a participating provider in central and eastern Pennsylvania in western Pennsylvania and Ohio *Additional fees apply for contact lens examinations. Your medical plan may already cover eye examinations. This discount is for subsequent eye exams once your existing eye exam benefit, if applicable, is exhausted. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you have questions call in central and eastern Pennsylvania, in western Pennsylvania and Ohio, or in northwestern Pennsylvania. This brochure is not a contract. It is intended solely to provide you with an overview of the plan and you should not rely on it when trying to determine whether a service, etc. is covered under your health plan benefit. Complete details of benefits, terms, and exclusions are set forth in the group contract. Pennsylvania in-area PPO and CCPPO (POS) products are underwritten by HealthAssurance Pennsylvania, Inc. (d.b.a. HealthAmerica). All indemnity products, out-of-area PPO products, HealthAmerica One products, and Ohio in-area PPO products are underwritten by Coventry Health and Life Insurance Company (d.b.a. HealthAmerica). HMO products are underwritten by HealthAmerica Pennsylvania, Inc. 01/11 (TDR-5m) HAH HealthAmerica
6 Preventive Care PREVENTIVE CARE HELPS KEEP YOU HEALTHY At Coventry Health Care, we encourage our policyholders to receive preventive care items and services. The Affordable Care Act percent. Our Coventry SM policies already provide coverage for many of those preventive services. Starting on October 1, 2010, policyholders of all new and renewing policies that are not grandfathered plans, as of the policyís effective or renewal COVERAGE FOR PREVENTIVE SERVICES Here are some examples of the preventive services that will be covered with no copay, coinsurance or deductible. Child Preventive Adult Preventive Exams: Immunizations: Pneumonia Hepatitis A Hepatitis B Diptheria, Tetanus, Pertussis Varicella (chicken pox) Measles, Mumps, Rubella (MMR) Polio Rotavirus Meningococcal Human Papillomavirus (HPV) Shingles Screening Tests: Hearing screening, Eye chart screening, PKU screening (newborns), Sickle cell screening (newborns) Newborn Preventive Treatment: Gonorrhea treatment Exams: Immunizations: Pneumonia Hepatitis A Hepatitis B Diptheria, Tetanus, Pertussis Varicella (chicken pox) Measles, Mumps, Rubella (MMR) Polio Rotavirus Meningococcal Shingles Screening Tests: Breast cancer screening, Cervical cancer screening, Colorectal cancer screening, Prostate cancer screening, Certain bone density screening, Lipid screening, Screening for sexually transmitted diseases, HIV test, Routine blood and urine screenings The list is subject to change as federal guidance is issued. The full list of covered preventive services issued with the Interim Final Rules can be found at COVERAGE FOR SPECIFIC DRUGS Aspirin (over-the-counter) ó Dose: 81 mg and 325 mg, men age 45 to 79 and women age 55 to 79. Iron (over-the-counter) ó Children up to age one, drops only. Folic Acid (over-the-counter) ó Dose: 400 mg and 800 mg, women. Fluoride ó Children under the age of six, drops and chewable tablets only Coventry Health Care, Inc. All rights reserved. COV1.MEM.PREV.CARE
7 Preventive Care TALKING WITH YOUR PROVIDER ABOUT PREVENTIVE CARE is administered during the same visit, cost-sharing may apply. This means your provider may ask you to pay your appropriate health plan copay, deductible or coinsurance. Certain screening services, such as a colonoscopy or mammogram, may identify health conditions that require further testing or treatment. If services and are subject to the appropriate cost-sharing. If you have questions about a claim or provider visit, please call the customer service number on your ID card or speak with your provider. Please regularly check our website for new information about preventive care coverage as the government
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