Coverage
Summary of Coverage
Lifetime Maximum Benefit: $1,000,000
Deductible Amount per Benefit Period:
(Benefit Period is Calendar Year)
$1,000 Medical / $250 Pharmacy or
$2,000 Medical / $500 Pharmacy or
$3,000 Medical / $500 Pharmacy or
$5,000 Medical / $750 Pharmacy or
$10,000 Medical / $1,000 Pharmacy
Out-of-Pocket Amount per Benefit Period: There is no limit on Out-Of-Pocket Amount under the policy.
Preventive/Wellness Services: 100%
Age and gender-specific preventitive health screening with a Network Provider, with no copay or deductible.
Prescription Drugs:
(subject to pharmacy deductible)
NOTE: The prescription drug benefits are available only through the Caremark National Network.
| Tier 1: Generic | $0* |
|
Tier 2: Preferred brand (Drugs listed on the CVS Caremark Performance Drug List) |
$25* |
|
Tier 3: Non-preferred brand (Drugs not listed on the CVS Caremark Performance Drug list) |
$50* |
|
Tier 4: Specialty (Drugs listed on the CVS Caremark Specialty Pharmacy Drug List) | $100* |
| *The amount you pay per prescription |
Subject to the Deductible Amount, the Association will
pay the percentage shown below toward Allowable Charges incurred by the policyholder.
Doctor Visits: 80%
Hospital Services: 80%
Ambulatory Surgical Facility: 80%
(Physician Services - M.D. and D.O. only)
Ambulance Services: 80%
(limited to $5,000 per calendar year and aggregate lifetime benefits
of $20,000.)
Durable Medical Equipment: 80%
(limited to $5,000 per calendar year and aggregate lifetime benefits
of $20,000.)
Limitations And Exclusions
The health insurance plan of the Association does not cover everything. Click here for Limitations and Exclusions.
See informational brochure for details
