Coventry One - Maryland Health Insurance Quotes - Sensible and Affordable Plans for Families and individuals in Maryland
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Coventry One  80% HSA Plan
Plan Design In-Network Out- of- Network
Get Coventry Health Insurance Quote For Maryland  
Lifetime maximum (per covered individual) $1,000,000
Deductible (per contract year)
- Choice of five deductible levels
$1200, $2400, $3000 Individual
(2x Family)
$2400, $4800, $6000 Individual
(2x Family)
Coinsurance Coverage pays 80%
You pay 20%
Coverage pays 60%
You pay 40%
Out-of-pocket maximum (per contract year) $3700, $4900, $5500 Individual
(2x Family)
$4900, $7300, $8500 Individual
(2x Family)
You Pay
You Pay
PCP office visit Deductible plus 20% Deductible plus 40%
Specialist office visit Deductible plus 20% Deductible plus 40%
Preventive office visit Same as PCP & Specialist office visit
Mammograms & Well-Child Visits
- Not subject to deductible
20% Coinsurance 40% Coinsurance
Emergency room services Deductible plus 20% Deductible plus 40%
Urgent care services Deductible plus 20% Deductible plus 40%
Ambulance (emergent)
- When medically necessary
Deductible plus 20% Deductible plus 40%
Inpatient hospital Deductible plus 20% Deductible plus 40%
Outpatient hospital / facility (X-ray, lab, diagnostic services, MRI, CAT & PET scans, surgery, anesthesia, etc.) Deductible plus 20% Deductible plus 40%
Short-term rehabilitation services ( chiropractic , physical, occupational or speech) Deductible plus 20% Deductible plus 40%
DME and Prosthetic devices
- Max. $2,000 per contract year per Member
Deductible plus 20% Deductible plus 40%
Transplant Services Deductible plus 20% Deductible plus 40%
Home health care
- Limit of 40 visits per contract year
Deductible plus 20% Deductible plus 40%
Skilled nursing facility
- Limited to 30 days per contract year
Deductible plus 20% Deductible plus 40%
- Inpatient limited to 30 days per contract year
Deductible plus 20% Deductible plus 40%
Prescription drugs* Maximum benefit $1,000 per contract year.
Deductible, then:
- Formulary generic drugs $0 Copay $0 Copay
- Formulary (brand) drugs $25 Copay $25 Copay
- Non-formulary (brand) drugs $50 Copay $50 Copay
Mental health and substance abuse Deductible plus 20% Deductible plus 40%
Exclusions and Limitations    
*Your CoventryOne PPO benefit plan provides coverage for out-of-network services. Many out-of-network services are covered ONLY if they are prior authorized. You are responsible for making sure that any services you receive from a non-participating provider are prior authorized. When you receive out-of-network covered services from a non-participating provider, you must pay applicable copayments, coinsurance, and deductibles. In addition, in most cases, the non-participating providers may bill you for charges that exceed our out-of-network rate. This amount could be substantial. Balances above the Out-of-Network Rate do NOT apply to your out-of-pocket maximum. The Out-of-Network Rate is the maximum amount covered by Us for approved out-of-network services. This rate will be derived from either
• a Medicare based fee schedule, or
• a percent of billed charges as determined by Us.
We will base the development of the rate on the following:
• Non-Participating Physicians Fees.
The Out-of-Network Rate is equivalent to 125% of the then-current Participating Provider Fee-Schedule, based on geographic region.
• Non-Participating Facility Fees.
• Inpatient facility services will be paid at the rate approved by the Health Services Cost Review Commission.
• Outpatient services rendered in a non-Hospital facility are paid at either
• Our Non-Participating non-Hospital fee schedule, which results in approximately 72% of the 2004 Medicare reimbursement schedule for ASC’s (“Ambulatory Surgical Centers”). For a copy of this fee schedule, please contact Customer Services; or
• If Medicare has not yet priced a particular code, 60% of billed charges for such code.
When We determine the Out-of-Network fee schedule, We reserve the right to apply
• proprietary reimbursement guidelines,
• claim adjudication procedures, and
• billing instructions.
This is not a contract or a definitive statement of benefits. It is intended solely to provide you with an overview of the proposed CoventryOne benefits. Complete details of benefits, terms and exclusions are governed by your CoventryOne Certificate of Insurance. The CoventryOne Certificate of Insurance may not cover all your health care expenses. Read your Certificate of Insurance carefully to determine which health care services are covered. If you have questions call us toll free at 1-800-833-7423.

* 3x for 3 month mail order supply
Coventry Home | Choice 80% PPO Plans | Coventry Legacy Plans | 80% HSA Plans | 100% HSA Plans is located at 4800 Hampden Ln Suite 200 Bethesda MD 20814 Toll Free (888)490-8782
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