Health Insurance Off-Exchange Plans for Individuals and Families in Missouri
Plan Name | Plans Offered On-Exchange | In-Network Providers | Out-of-Network Providers | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Office Visit
(PCP / Specialist) |
Deductible, Single
(x2 family) |
Coinsurance | Out-of-Pocket Maximum1
(x2 family) |
Pediatric Vision Exam and Standard Hardware | Preventive Pediatric Dental*
(Off-Exchange Only) |
Inpatient Hospital | Outpatient Surgery | Emergency Room /
Urgent Care |
Deductible Single
(x2 family) |
Coinsurance | Out-of-Pocket Maximum1
(x2 family) |
||
Gold 80% Coinsurance HMO Plan^ | 80% Coinsurance | N/A | 80% | $5,500 | $0 | $0 | Coinsurance | Coinsurance | Coinsurance | N/A | N/A | N/A | |
Gold $10 Copay PPO Plan | ✓ | (PCP) $10 / (SPC) First 5 Visits: $50 copay; 6 Visits: $50 Copay + Ded. | $1,750 | 80% | $5,000 | $0 | $0 | Ded. then coinsurance | Ded. then coinsurance | First 3 Visits: $250 Copay; 4+ visits: $250 Copay + Ded. / $75 | $5,500 | 70% | $10,000 |
Silver $15 Copay PPO Plan | ✓ | (PCP) $15 / (SPC) First Visit: $75 copay; 2+ Visits: $75 Copay + Ded. | $3,750 | 70% | $6,350 | $0 | $0 | $500+ Ded. then coinsurance | $250+ Ded. then coinsurance | First Visit: $500 Copay; 2+ Visits: $500 Copay + Ded. / $75 | $6,400 | 50% | $12,800 |
Bronze Deductible Only PPO HSA Eligible Plan | ✓ | Deductible | $6,300 | 100% | $6,300 | $0 | $0 | Deductible | Deductible | Deductible | $6,400 | 50% | $12,800 |
Bronze $15 Copay PPO Plan | ✓ | (PCP) $15 / (SPC) $75 Copay + Ded. | $5,600 | 70% | $6,350 | $0 | $0 | $500+ Ded. then coinsurance | $250+ Ded. then coinsurance | $500 + Ded. / $75 + Ded. | $6,400 | 50% | $12,800 |
Catastrophic 100% PPO Plan** | ✓ | (PCP) First 3 visits: $25 Copay; 4+ visits: Ded. / (SPC) Ded. | $6,350** | 100% | $6,350** | $0 | $0 | Deductible | Deductible | Deductible | $6,400** | 50% | $12,800** |
Metal Value
Gold: 80% actuarial value
Silver: 70% actuarial value
Bronze: 60% actuarial value
Catastrophic: < 60% actuarial value
Gold: 80% actuarial value
Silver: 70% actuarial value
Bronze: 60% actuarial value
Catastrophic: < 60% actuarial value
Prescription Drug Plan-Retail | |||||||
---|---|---|---|---|---|---|---|
Rx Plans Available | Gold 80% Coinsurance HMO Plan | Gold $10 Copay PPO Plan | Silver $15 Copay PPO Plan | Bronze Deductible Only PPO HSA Eligible Plan | Bronze $15 Copay PPO Plan | Catastrophic 100% PPO Plan** | |
Retail Preferred | Tier 1A | 50% | $3 | $5 | Deductible | $15 | Deductible |
Tier 1 | 50% | $5 | $15 | Deductible | $15 | Deductible | |
Tier 2 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $30 | $1,000 Rx Ded. + $45 | Deductible | Ded. + $45 | Deductible | |
Tier 3 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $60 | $1,000 Rx Ded. + $75 | Deductible | Ded. + $75 | Deductible | |
Tier 4 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + 20% | $1,000 Rx Ded. + 30% | Deductible | Ded. + 30% | Deductible | |
Tier 5 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + 30% | $1,000 Rx Ded. + 40% | Deductible | Ded. + 40% | Deductible | |
Retail Non-Preferred | Tier 1A | 50% | $10 | $20 | Deductible | $20 | Deductible |
Tier 1 | 50% | $10 | $20 | Deductible | $20 | Deductible | |
Tier 2 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $40 | $1,000 Rx Ded. + $55 | Deductible | Ded. + $55 | Deductible | |
Tier 3 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $75 | $1,000 Rx Ded. + $85 | Deductible | Ded. + $85 | Deductible | |
Tier 4 | $1,000 Rx Ded. + 50% | $250 Rx. Ded + 20% | $1,000 Rx Ded. + 30% | Deductible | Ded. + 30% | Deductible | |
Tier 5 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + 30% | $1,000 Rx Ded. + 40% | Deductible | Ded. + 40% | Deductible | |
Mail Order | Tier 1A | 50% | $6 | $10 | Deductible | $30 | Deductible |
Tier 1 | 50% | $10 | $30 | Deductible | $30 | Decuctible | |
Tier 2 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $75 | $1,000 Rx Ded. + $112.50 | Deductible | Ded. + $112.50 | Deductible | |
Tier 3 | $1,000 Rx Ded. + 50% | $250 Rx Ded. + $180 | $1,000 Rx Ded. + $225 | Deductible | Ded. + $225 | Deductible |
All benefits for all plans are administered on a calendar year basis.
There are no Lifetime Maximum Limits.
Chiropractic: Member Responsibility Applies; 26 visits.
1 Out-of-pocket maximums include deductible, coinsurance, copay and pharmacy.
* Basic and Major Pediatric dental procedures receive 50% coverage after deductible.
** When more than one person is applying for coverage, the Family Deductible and out-of-pocket maximum must be met before any benefits are paid that are subject to the Deductible or out-of-pocket maximum.
^ County restrictions apply.
There are no Lifetime Maximum Limits.
Chiropractic: Member Responsibility Applies; 26 visits.
1 Out-of-pocket maximums include deductible, coinsurance, copay and pharmacy.
* Basic and Major Pediatric dental procedures receive 50% coverage after deductible.
** When more than one person is applying for coverage, the Family Deductible and out-of-pocket maximum must be met before any benefits are paid that are subject to the Deductible or out-of-pocket maximum.
^ County restrictions apply.
CoventryOne is a heath insurance product in Missouri underwritten by Coventry Health Care of Missouri, Inc. and/or Coventry Health and Life Insurance Company. This information is a partial description of the benefits, limitations, or exclusions of the plan. Please refer to the Individual Policy, Schedule of Benefits and applicable Riders to determine exact terms, conditions and scope of coverage, including all exclusions and limitations and defined terms.