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Beneficios Plan Z Coventry One/Open Access Focused Deductible HMO Z Plans


           Beneficios                         

Primary Care Office Visit

Specialist Office Visit

Urgent Care

Emergency Room
(at a participating hospital)

Emergency Room
(at a non-participating hospital)

Inpatient Hospital

Outpatient Diagnostic Services
(at a Hospital)

Outpatient Diagnostic Services
(at a Freestanding Facility)

Outpatient Surgery
(at a Hospital)

Outpatient Surgery
(at an Ambulatory Surgical Center)

Preventive Dental & Vision

Deductible (hospital only)

Out-of-Pocket Maximum

              Prescription Drug      

Tier One (Generic Drugs)

Tier Two (Brand Name Formulary Drugs)


Deductible




Maximum Benefit


 
Z-2500 

$30

$50

$50

$500


$500
after deductible

$500 / day (1-5)
after deductible
$250
after deductible

$250


$500
after deductible


$500

Included

$2,500

$5,000



$15
unlimited benefit
$60 after deductible

$500
applies to formulary
brand name drugs


$1,200applies to formulary
brand name drugs



 Z-5000  


$30

$50

$50

$500


$500
after deductible

$500 / day (1-5)
after deductible
$250
after deductible

$250


$500
after deductible


$500

Included

$5,000

$5,000



$15
unlimited benefit
$60 after  deduc

$500
applies to formulary
brand name drugs

$1,200applies to formulary
brand name drugs
 

 
Z-7500  


$30

$50

$50

$500


$500
after deductible

$500 / day (1-5)
after deductible
$250
after deductible

$250


$500
after deductible


$500

Included

$7,500

$5,000



$15
unlimited benefit
$60after deductible

$500
applies to formulary
brand name drugs

$1,200applies to formulary
brand name drugs
 


Z-10000 


$30

$50

$50

$500


$500
after deductible

$500 / day (1-5)
after deductible
$250
after deductible

$250


$500
after deductible


$500

Included

$10,000

$5,000



$15
unlimited benefit
$60 after deductible

$500
applies to formulary
brand name drugs

$1,200applies to formulary
brand name drugs



All Focused Deductible Z plans are Open Access, no referrals needed.
Copays apply to the out-of-pocket maximum for all benefits except pharmacy. Deductible does not apply towards Out-of-Pocket Maximum.
Pharmacy deductible and maximum benefit apply to Tier Two only on all Focused Deductible Z plans.
Optional maternity Rider available for all benefit plan options.

This is a brief summary description of benefits. Refer to plan documents for a complete list of covered services and limitations
or exclusions.
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