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: Prescription Drug benefit is limited to $100,000 per year..
| Tier 1: Drugs | 100% after $10 Co-pay |
| Tier 2: Drugs | 100% after $35 Co-pay |
| Tier 3: Drugs | 100% after $75 Co-pay |
| Tier 4: Specialty (Drugs listed on the CVS Caremark Specialty Pharmacy Drug List) | 100% after 10% Coinsurance, $100 minimum / $200 maximum amount of coinsurance |
The prescription drug benefits are available only through the Caremark National Network. A Caremark National Network Pharmacy is a Network Provider. A pharmacy that is not a Caremark National Network Pharmacy is a Non-Network Provider. Pharmacy Benefits are not provided through Non-Network Providers. If a high quality Generic Alternative is available, but the Policyholder purchases the brand name drug, the Policyholder will pay the applicable co-pay plus the cost difference between the brand name drug and the generic drug prices.
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.
Click here to download the Informational Brochure.