health insuranCe Plans
PremierChoiCe
• Designed for Individuals, Families and Self Employed • Comprehensive $5,000,000/Person Lifetime Maximum • Practical $250,000 Annual Maximum • Extensive Network with Out of Network Options
Issued to Members of: Savers Choice of America Association
Central United Life Insurance Company
PCHP-0209
Your PremierChoice Plan Provides healthcare choices to suit your Individual needs and budget. The Choice is up to You!
• You choose the calendar year deductible - the higher the deductible the lower the premium! • You choose the coinsurance level! • You choose the benefit options to fit your budget and insurance needs! Your PremierChoice plan helps you balance your health insurance needs. With higher deductibles and coinsurance, you are paying more of your routine medical expenses. You use our coverage for higher cost expenses which lowers your insurance costs and lets you budget your medical and insurance expenses.
Two Affordable Plans to choose from . . .
SelectChoice - for those who utilize First Dollar coverage (after co-pay) on an outpatient basis. SaversChoice - for those who want lower premiums by choosing a plan that first meets a calendar year deductible.
Covered Charges (subject to deductible and coinsurance)
• Hospital Expenses • Emergency Room - 2 visits per year • Physician’s Office Visits – includes Allergy Injections • Diagnostic Laboratory & X-Ray • Durable Medical Equipment - Rental/Purchase ($1,000 calendar year maximum) • Wellness Services - limited to $500 calendar year maximum; Includes 100% Childhood Immunization,
Infant Hearing Screening, Other.
• Ambulance Service - Land $500 calendar year maximum benefit
- Air $1,000 calendar year maximum benefit
• Rehabilitative Services - limited to 2 visits per calendar year with a maximum benefit of $50 per visit • Skilled Nursing Care - limited to 30 days each calendar year • Hospice Counseling - visits limited to 2 for counseling and 1 for bereavement. • Hospice Care - limited to Lifetime Maximum benefit of $10,000 • Home Health Care - limited to 120 hours (in TX, 60 visits) each calendar year • Organ Transplant - $250,000 Patient, $10,000 Organ Donor Lifetime Maximum
(services 14 days before and 365 following transplantation).
• Outpatient vertebrae, disc, spine, back, neck and joint - $750 per year • Anti-nausea, side-effect and enhancer drugs for cancer treatment - $50,000 per year • In IL and TX only, Serious Mental Illness - 45 inpatient days and 60 outpatient visits per year
seleCtChoiCe
SELECT CHOICE PLAN
Association Medical Plan
Calendar Year Maximum Benefit Lifetime Maximum Benefit Calendar Year Deductible $1,000 $250,000 $5 Million $2,500 $5,000
Maximum 3 individual calendar year deductibles per family.
Coinsurance/Stop Loss – Your Choice of out of pocket after covered person has satisfied calendar year deductible and any service deductibles and co-pays. PPO & Non PPO stop loss amounts accumulate separately.
PPO – Stop Loss 80/20% - $5,000 80/20% - $10,000 50/50% - $10,000
Non PPO - Stop Loss 60/40% - $10,000 60/40% - $20,000 50/50% - $20,000
First 4 In-network office visits are covered under your co-pay. The remaining in-network and all out of network visits are subject to deductible and coinsurance. Physician Office Visit Co-pay applies to the physician office visit charge This includes covered lab exams, x-rays and diagnostic tests to a maximum benefit of $100. Co-pays: Regular Office Visit: $35 Specialist Visit: $60
Service Deductibles
Hospital Emergency Room (per occurrence; 2 visits per year) Inpatient Hospital Admission Outpatient Surgical Facility Outpatient MRI, Cat Scan, PET Scan and Nuclear Imaging Test (per test) $200 $200 $200 $200
saversChoiCe
SAVERS CHOICE PLAN
Association Medical Plan
Calendar Year Maximum Benefit Lifetime Maximum Benefit Calendar Year Deductible $1,000 $250,000 $5 Million $2,500 $5,000
Maximum 3 individual calendar year deductibles per family.
Coinsurance/Stop Loss – Your Choice of out of pocket after covered person has satisfied calendar year deductible and any service deductibles and co-pays. PPO & Non PPO stop loss amounts accumulate separately.
PPO – Stop Loss 80/20% - $5,000 80/20% - $10,000 50/50% - $10,000
Non PPO - Stop Loss 60/40% - $10,000 60/40% - $20,000 50/50% - $20,000
Service Deductibles
Hospital Emergency Room (per occurrence; 2 visits per year) Inpatient Hospital Admission Outpatient Surgical Facility Outpatient MRI, Cat Scan, PET Scan and Nuclear Imaging Test (per test) (available at an additional premium) The Pharmacy Rider can be added to either the SelectChoice or SaversChoice plan. A covered person must first meet the Rx deductible of $500 for formulary and non-formulary drugs. Once the deductible is satisfied, covered expenses will be subject to the following:
Deductible Generic Formulary/Non-Formulary Participating Pharmacy (Not to exceed a 30 day supply) Generic Drugs Formulary Drugs Non-Formulary Drugs Non-Participating Pharmacy (Not to exceed a 30 day supply) (in PA, cost is 80% less) Generic Drugs Formulary Drugs Non-Formulary Drugs $0 $500 per Calendar Year per covered person 100% less the $10 Co-payment 100% less the $25 Co-payment 100% less the $25 Co-payment
$200 $200 $200 $200
PharmaCy rider
70% less the $10 Co-payment 70% less the $25 Co-payment 70% less the $25 Co-payment
Mail Service Legend Prescription Drugs (Not to exceed a 90 day supply through Our designated mail order vendor) Generic Drugs 100% less the $20 Co-payment Formulary Drugs 100% less the $50 Co-payment Non-Formulary Drugs 100% less the $50 Co-payment Benefit Maximum for all Prescriptions $2,000 per Calendar Year per covered person