CoventryOne QHDHP 10 (Family)

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
CoventryOne QHDHP 10 (Family)
Plan ID
41614SC0020031
Plan Year
2013
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
CoventryOne
Plan Type
POS
Deductible
0
Out-of-Pocket Maximum
0
Plan Highlights

Cost & Coverage

Estimated Monthly Base Rate
Estimated monthly premium starts at $80.06
How many applications are denied?
14% of the applicants were denied
How accurate is this estimate?
19% of the applicants ended up paying a higher amount than the quoted price
Deductible
Individual: N/A
Family: $9000
In-Network Out-of-Pocket Limit
Individual: N/A
Family: $9000
What is included in the in-network out-of-pocket limit?
Deductible + Coinsurance + Co-pay
Is this plan Health Savings Account (HSA) eligible?
No
How can I find a doctor in this plan's network?
Plan Type
POS

Health Services Options

Service
In Network
Out of Network
Primary care physician office visit
No Charge after deductible
30% Coinsurance after deductible
Specialist
No Charge after deductible
30% Coinsurance after deductible
Diagnostic Test (X-ray, blood work)
No Charge after deductible
30% Coinsurance after deductible
Outpatient Facility Fee
No Charge after deductible
30% Coinsurance after deductible
Outpatient Physician/Surgeon Fee
No Charge after deductible
30% Coinsurance after deductible
Hospital facility fee
No Charge after deductible
30% Coinsurance after deductible
Hospital physician/surgeon fee
No Charge after deductible
30% Coinsurance after deductible
Emergency Room
No Charge after deductible
No Charge after deductible

Drug Services

Generic Drugs
Coverage: No Charge after deductible
Preferred Brand Drugs
Coverage: No Charge after deductible
Specialty Drugs
Coverage: No Charge after deductible
What drugs are covered in the formulary?

Mental Health or Substance Abuse Services

Service
In Network
Out of Network
Mental/behavioral health outpatient services
Not Covered
Not Covered
Mental/behavioral health inpatient services
Not Covered
Not Covered
Substance use disorder inpatient services
Not Covered
Not Covered
Substance use disorder outpatient services
Not Covered
Not Covered

Maternity Services

Service
In Network
Out of Network
Prenatal/postnatal care
Not Covered
Not Covered
Delivery and all inpatient services for maternity care
Not Covered
Not Covered

Coverage Options Summary

Included Benefits
  • Durable medical equipment
  • Emergency Transportation
  • Home health care
  • Hospice
  • Imaging (CT/PET scans, MRIs)
  • Inpatient rehabilitation
  • Non-preferred brand drugs
  • Skilled nursing care
  • Other practitioner office visit
  • Outpatient rehabilitation
  • Preventive care, screening, immunization
  • Routine eye exam children
  • Urgent Care
Excluded Benefits
  • Acupuncture
  • Bariatric surgery
  • Cosmetic surgery
  • Dental care adult
  • Dental check up children
  • Eye exam adult
  • Eye glasses children
  • Habilitation
  • Hearing Aid
  • Infertility treatment
  • Long Term Care
  • Non-emergency care outside U.S.
  • Private duty nursing
  • Routine foot care
  • Routine hearing tests
  • Weight loss program
Limited Benefits
  • Chiropractic

What To Know

  • 14%of the applicants were denied
  • 19%of the applicants ended up paying a higher amount than the quoted price

Physician Directory

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