CoreMed® Individual Medical Insurance

CoreMed® Individual Medical Insurance

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Plan Design Unless otherwise noted, all deductibles, maximums and benefit amounts are applied per person and are reset each January 1.

Deductible

Amount you pay toward covered expenses before the plan pays benefits

$500, $1,000, $1,500, $2,000, $3,000, $5,000 or $10,000

(Family deductible maximum is two times the deductible and is met collectively by two or more persons)

Benefit Percentage

Percentage of covered expenses the plan pays after the deductible 80%, 70% or 50%

Coinsurance

Percentage of covered expenses you pay after the deductible 20%, 30% or 50%

Coinsurance Out-Of-Pocket Maximum

After this maximum is met, the plan pays 100% of covered expenses $1,250 to $7,500 depending on coinsurance

(Family coinsurance out-of-pocket maximum is two times the coinsurance out-of-pocket maximum and is met collectively by two or more persons)

Lifetime Benefit Maximum

The total maximum amount the plan pays $2 million or $6 million

Outpatient Benefits Benefits are subject to deductible and coinsurance unless otherwise noted.

Prescription Drugs - Generic $15 copay (no deductible)

Prescription Drugs - Brand name $500 deductible / $25 copay + 50% coinsurance

(Family deductible maximum is $1,000 and is met collectively by two or more persons)

Preventive Services

Mammograms, Pap smears, PSA screening, newborn screening tests and diagnostic follow up for hearing loss, and childhood immunizations.*

Covered after you have been insured for 12 months

Other preventive services and office visits Up to $500 in benefits—after you have been insured for 12 months

• Copay, if selected, applies to office visits

Office Visits Covered

Office Visit Copay

Optional benefit

$35 copay for each of four network office visits per person

• Visits for illness, injury and (after 12 months) preventive services are eligible

• Additional visits are covered subject to deductible and coinsurance

Diagnostic Imaging and Laboratory Services Covered

Outpatient Hospital, Surgical Center or Urgent Care Facility Covered

• Outpatient facility fee: $0 or $200 per outpatient surgery

Professional Ground and Air Ambulance Covered

Emergency Room Covered

• $75 emergency room fee—waived if admitted to the hospital

Health Care Practitioner Services Covered

Outpatient Physical Medicine Up to $3,000 in benefits

Home Health Care Up to 160 hours

Inpatient Benefits Benefits are subject to deductible and coinsurance unless otherwise noted.

Inpatient Hospital Covered

• Inpatient facility fee: $0, $200 or $750 per day for first three days of each confinement

($0 available with $0 outpatient, $200 and $750 available with $200 outpatient)

Inpatient Rehabilitation Facility Up to 90 days

Subacute Rehabilitation and Skilled Nursing Facilities Up to 90 days

Transplants Covered

Behavioral Health and Substance Abuse Not covered

Optional Features Optional features are available at an additional cost.

Optional Benefits and Discount Programs

Discount programs are not insurance

SuiteSolutions, Office Visit Copay, Maternity Benefit,

Accident Medical Expense, Supplemental Life and

Dental/Vision Discount Card

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