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CoventryOne 100% Legacy PPO $5000 Deductible | PCP Doc Visit $30 / Specialist $40
Plan Design In-Network Out- of- Network 
Get Coventry Health Insurance Quote For Maryland  
Lifetime maximum (per covered individual) $2,000,000
Deductible (per contract year)
- Choice of five deductible levels
$5,000 Individual
$10,000 Family
$10,000 Individual
$20,000 Family
Coinsurance Coverage pays 100%
You pay 0%
Coverage pays 80%
You pay 20%
Out-of-pocket maximum (per contract year) Deductible equals $5,000 Deductible and $2,000 coinsurance
You Pay
You Pay
PCP office visit $30 Copay Deductible plus 20%
Specialist office visit $40 Copay Deductible plus 20%
Preventive office visit Same as PCP & Specialist office visit
Mammograms & Well-Child Visits
- Not subject to deductible
$30 PCP Copay $40 Specialist Copay 20% Coinsurance
Emergency room services $200 Copay
(waived if admitted)
$200 Copay
(waived if admitted)
Urgent care services $40 Copay $40 Copay
Ambulance (emergent)
- When medically necessary
Deductible Deductible plus 20%
Inpatient hospital Deductible Deductible plus 20%
Outpatient hospital / facility (X-ray, lab, diagnostic services, MRI, CAT & PET scans, surgery, anesthesia, etc.) Deductible Deductible plus 20%
Short-term rehabilitation services ( chiropractic , physical, occupational or speech) Deductible
(up to 24 visits per contract year per service)
Deductible plus 20%
(up to 24 visits per contract year per service)
DME and Prosthetic devices
- Max. $2,000 per contract year per Member
Deductible Deductible plus 20%
Transplant Services Deductible Deductible plus 20%
Home health care
- Limit of 40 visits per contract year
Deductible Deductible plus 20%
Skilled nursing facility
- Limited to 30 days per contract year
Deductible Deductible plus 20%
- Inpatient limited to 30 days per contract year
Deductible Deductible plus 20%
Prescription drugs* Maximum benefit $1,500 per contract year
- Formulary generic drugs $10 copay $10 Copay
- Formulary (brand) drugs Not Covered Not Covered
- Non-formulary (brand) drugs Not Covered Not Covered
Mental health and substance abuse See Appropriate Schedule of Benefits
  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.

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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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