Coventry Plan Options

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

 

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.

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.