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| BENEFITS |
COREGUARD PLUS |
| Calendar Year Deductible |
Your Choices (choose from 7 low-cost plans) |
| Individual |
$750
$750 |
$1,500
$1,500 |
$2,500
$2,500 |
$3,500
$3,500 |
$5,000
$5,000 |
$7,500
$7,500 |
$10,000
$10,000 |
Network
Non-Network |
| Family |
$1,500
$1,500 |
$3,000
$3,000 |
$5,000
$5,000 |
$7,000
$7,000 |
$10,000
$10,000 |
$15,000
$15,000 |
$20,000
$20,000 |
Network
Non-Network |
| Network Coinsurance Options |
50% |
50% |
50% |
50% |
50% |
50% |
0% |
|
| Calendar Year Out-of-Pocket Maximum |
Add your chosen Deductible to the amount below |
| Individual |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
$3,500
$7,500 |
$0
$7,500 |
Network
Non-Network |
| Family |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
$7,000
$15,000 |
$0
$15,000 |
Network
Non-Network |
| How family deductibles and family out-of-pocket maximums work |
Once one family member reaches their individual deductible or out-of-pocket maximum, the remaining amount of the family deductible or out-of-pocket maximum needs to be met by one or more other family members. The family deductible or out-of-pocket maximum can be met by the family combined. |
| Lifetime Maximum |
Unlimited |
| Covered Services |
Your share of costs (after deductible) |
| Doctors' Office Visits |
NETWORK: 50% Coinsurance (or 0% Coinsurance with $10,000 plan)
NON-NETWORK: 70% Coinsurance (or 30% Coinsurance with $10,000 plan) |
| Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) |
NETWORK: 50% Coinsurance (or 0% Coinsurance with $10,000 plan)
NON-NETWORK: 70% Coinsurance (or 30% Coinsurance with $10,000 plan) |
Inpatient Services
(overnight hospital/facility stays) |
NETWORK: 50% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
50% Coinsurance (with $3,500, $5,000, $7,500)
0% Coinsurance (with ($10,000)
NON-NETWORK: 70% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
70% Coinsurance (with $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
Outpatient Services
(No overnight hospital/facility stays) |
NETWORK: 50% Coinsurance PLUS $200 Facility Copay per admission (with $750, $1,500, $2,500)
50% Coinsurance (with $3,500, $5,000, $7,500)
0% Coinsurance (with ($10,000)
NON-NETWORK: 70% Coinsurance PLUS $200 Facility Copay per admission (with $750, $1,500, $2,500)
70% Coinsurance (with $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
| Emergency Room Services |
NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted)
NON-NETWORK: 40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted) |
| Preventive Care Services |
NETWORK: 0% Coinsurance, not subject to deductible
NON-NETWORK: 100% Coinsurance; then 50% Coinsurance after out-of-pocket max is met |
| Maternity |
Not Covered |
Optional Coverages
(for additional cost) |
Dental, Life |
Prescription Drugs:
Retail Drugs (and Mail Order Drugs when available) |
NETWORK:
Tier 1 (Generic Drugs): $15 Copay
$7,500 annual Prescription Drug deductible per member applies before the following:
Tier 2 (Formulary Brand name drugs): $40 Copay
Tier 3 (Non-formulary Brand name drugs): $60 Copay
Specialty: 25% Coinsurance up to $2,500 annual Prescription Drug out-of-pocket max (the most you'll have to pay),
for network only and in additional to $7,500 annual deductible.
NON-NETWORK: Not Covered |
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