BST_NAIC_BW 72600 Fl72600
User Manual: 72600
Open the PDF directly: View PDF 
.
Page Count: 8
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
In network: $1,750 person/$3,500 family.
Does not apply to PCP, First 5 Specialist
visits, Urgent Care, First 3 visits ER visits,
ER Transportation/Ambulance, Prenatal
office visits, Advanced Imaging in
freestanding facility, Preventive Care and
Pediatric Vision Screening and Eye
Out of network: Not Covered
You must pay all the costs up to the deductible amount before this plan begins to
pay for covered services you use. Check your policy or plan document to see when
the deductible starts over (usually, but not always, January 1st). See the chart starting
on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles
for specific services?
Yes $250 Prescription. There are no other
specific deductibles.
You must pay all of the costs for these services up to the specific deductible amount
before this plan begins to pay for these services.
Is there an out-of-pocket
limit on my expenses?
In network: Yes $5,000 person/$10,000
family
Out of network: Not Covered
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
What is not included in the
out-of-pocket limit?
Premiums, excluded services and health
care this plan does not cover.
Even though you pay these expenses, they don't count toward the out-of-pocket
limit.
Is there an overall annual
limit on what the plan pays?
No
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes
For a list of participating providers, see
chcflorida.com or call 1-855-449-2889.
If you use an in-network doctor or other health care provider, this plan will pay some
or all of the costs of covered services. Be aware, your in-network doctor or hospital
may use an out-of-network provider for some services. Plans use the term in-
network, preferred, or participating for providers in their network. See the chart
starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a
specialist?
Yes
This plan will pay some or all of the costs to see a specialist for covered services but
only if you have the plan’s permission before you see the specialist.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the
policy or plan document at chcflorida.com or by calling 1-855-449-2889.
Coventry Health Care of Florida, Inc.: Gold $5 Copay HMO Carelink
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period : 01/01/2014 - 12/31/2014
Coverage for:
EE only, EE/Spouse,
EE/Child(ren), EE/Family
| Plan Type:
HMO
Page 1 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
Important Questions
Answers
Why This Matters:
Are there services this plan
doesn't cover?
Yes. Some of the services this plan doesn't
cover are listed in Services Your Plan
Does Not Cover. See your Certificate of
Coverage for additional information about
excluded services.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or
plan document for additional information about excluded services.
Your cost if you use a
Common Medical Event
Services You May Need
In-network
Provider
Out-of-network
Provider
Limitations & Exceptions
If you visit a health care
provider's office or clinic
Primary care visit to treat an
injury or illness
$5 co-payment (co-
pay)/occurrence
Not Covered
----------none----------
Specialist visit
$50 co-pay/occurrence
Not Covered
----------none----------
Other practitioner office visit
$50 co-pay/occurrence
(chiropradtic care).
Not Covered
Limited: 26 visits/year
Preventive care/
Screening/Immunization
No Charge
Not Covered
----------none----------
If you have a test
Diagnostic test (x-ray, blood
work)
$0 in PCP office x-ray
$0 in PCP office lab
Not Covered x-ray
Not Covered lab
----------none----------
Imaging (CT/PET scans,
MRIs)
$250 co-pay/occurrence
at freestanding facility
Not Covered
Not covered without preauthorization
(preauth)
•Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
•Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you
haven't met your deductible.
•The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
•This plan may encourage you to use In network providers by charging you lower deductibles, copayments and coinsurance amounts.
Page 2 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
Your cost if you use a
Common Medical Event
Services You May Need
In-network
Provider
Out-of-network
Provider
Limitations & Exceptions
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
chcflorida.com.
Generic drugs
$5 co-pay/fill retail
preferred , $10 co-
pay/fill retail non
preferred , $10 co-
pay/fill mail.
Not Covered
Includes $3 co-pay/fill retail preferred generics,
$10 co-pay/fill retail non preferred, $6 co-
pay/fill mail. Limited: 30-day supply retail, 90-
day supply mail. May require preauth for
coverage.
Preferred brand drugs
$30 co-pay/fill retail
preferred, $75 co-pay/fill
mail.
Not Covered
$40 co-pay/fill retail non preferred, $75 co-
pay/fill mail. Limited: 30-day supply retail, 90-
day supply mail. May require preauth for
coverage.
Non-preferred brand drugs
$60 co-pay/fill retail
preferred, $180 co-
pay/fill mail.
Not Covered
$75 co-pay/fill retail non preferred, $180 co-
pay/fill mail. Limited: 30-day supply reatil, 90-
day supply mail. May require preauth for
coverage.
Specialty drugs
20% co-ins retail
preferred
Not Covered
30% co-ins retail non preferred. Limited: 30-
day supply. May require preauth for coverage.
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
$250 co-pay/occurrence
at Freestanding Facility
Not Covered
----------none----------
Physician/surgeon fees
20% co-ins
Not Covered
----------none----------
If you need immediate
medical attention
Emergency room services
$250 co-pay/occurrence
$250 co-pay/occurrence
Must meet emergency room criteria.
Emergency medical
transportation
$500 co-pay/occurrence
$500 co-pay/occurrence
----------none----------
Urgent care
$75 co-pay/occurrence
Not Covered
----------none----------
If you have a hospital stay
Facility fee (e.g., hospital
room)
20% co-ins
Not Covered
Consequence for no preauth if required.
Physician/surgeon fee
20% co-ins
Not Covered
Consequence for no preauth if required.
If you have mental health,
behavioral health, or
substance abuse needs
Mental/Behavioral health
outpatient services
$50 co-pay/occurrence
Not Covered
Limited: 20 visits/year.
Mental/Behavioral health
inpatient services
20% co-ins
Not Covered
Limited: 30 days/year and consequence for no
preauth if required.
Substance use disorder
outpatient services
$50 co-pay/occurrence
Not Covered
Limited: 20 visits/year.
Page 3 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
Your cost if you use a
Common Medical Event
Services You May Need
In-network
Provider
Out-of-network
Provider
Limitations & Exceptions
If you have mental health,
behavioral health, or
substance abuse needs
Substance use disorder
inpatient services
20% co-ins
Not Covered
Limited: 30 days/year and consequence for no
preauth if required.
If you are pregnant
Prenatal and postnatal care
$0
Not Covered
One time $250 Co-pay Physician
Services/Ultrasound
Delivery and all inpatient
services
20% co-ins
Not Covered
Consequense for no preauth if required.
If you need help
recovering or have other
special health needs
Home health care
20% co-ins
Not Covered
Limited: 20 visits/year and consequence for no
preauth if required.
Rehabilitation services
Inpatient 20% co-ins
Outpatient 20% co-ins
Inpatient Not Covered
Outpatient Not
Covered
Consequense for no preauth if required.
Habilitation services
20% co-ins
Not Covered
Consequence for no preauth if required.
Skilled nursing care
20% co-ins
Not Covered
Limited: 60 days/year and consequence for no
preauth if required.
Durable medical equipment
20% co-ins
Not Covered
Consequence for no preauth if required.
Hospice Service
20% co-ins
Not Covered
Consequence for no preauth if required.
If your child needs dental
or eye care
Eye exam
$0
Not Covered
Limited: 1 routine eye exam/year.
Glasses
$0
Not Covered
Limited: 1 pair eyeglasses/lenses/year. 1
frame/year.
Dental check-up
Not Covered
Not Covered
Excluded Service
Page 4 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•Acupuncture
•Bariatric Surgery
•Child/Dental Check-up
•Cosmetic Surgery
•Dental Care (Adult)
•Hearing Aids
•Infertility Treatment
•Long-Term Care
•Non-Emergency Care when Traveling
Outside the U.S.
•Private-Duty Nursing
•Routine Eye Care (Adult)
•Routine Foot Care
•Weight Loss Programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
•Chiropractic Care
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while
covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-855-449-2889. You may also contact your state insurance department, the U.S.
Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa , or the U.S. Department of Health and Human Services
at 1-877-267-2323 x61565 or www.cciio.cms.gov .
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact:
For group health coverage subject to ERISA, you may contact 1-855-449-2889. You may also contact, the Department of Labor's Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , or your state department of insurance at Florida Department of Financial Services
Division of Consumer Services 200 E. Gaines St. Tallahassee, FL 32399-0322 877-693-5236 www.myfloridacfo.com/Division/Consumers/NeedOurHelp.htm.
For non-federal governmental group health plans and church plans that are group health plans, you may contact 1-855-449-2889 or your state department of
insurance at Florida Department of Financial Services Division of Consumer Services 200 E. Gaines St. Tallahassee, FL 32399-0322 877-693-5236
www.myfloridacfo.com/Division/Consumers/NeedOurHelp.htm.
Does this Coverage Provide Minimum Essential Coverage?
Page 5 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide
minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health
coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Espanol): Para obtener asistencia en Espanol, llame al 1-855-449-2889.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-449-2889.
Chinese ĩᷕ㔯ĪĻơġ⤪㝄暨天ᷕ㔯䘬ⷖ≑炻実㊐ㇻ征᷒⎟䞩ġ1-855-449-2889.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-449-2889.
––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––
Page 6 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
About these Coverage
Examples:
These examples show how this plan
might cover medical care in given
situations. Use these examples to see, in
general, how much insurance
protection you might get from different
plans.
Amount owed to providers:
$7,540
Plan pays:
$4,930
You pay:
$2,610
Sample care costs:
Hospital charges (mother)
$2,700
Routine Obstetric Care
$2,100
Hospital Charges (baby)
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
Vaccines, other preventive
$40
Total
$7,540
You pay:
Deductibles
$1,800
Co-pays
$10
Coinsurance
$600
Limits or exclusions
$200
Total
$2,610
Amount owed to providers:
Plan pays:
$3,760
You pay:
$1,640
Sample care costs:
Prescriptions
$2,900
Medical equipment and supplies
$1,300
Office Visits and Procedures
$700
Education
$300
Laboratory tests
$100
Vaccine, other preventive
$100
Total
$5,400
You pay:
Deductibles
$300
Co-pays
$1,300
Coinsurance
$0
Limits or exclusions
$40
Total
$1,640
Note: These numbers assume the patient is participating in
our diabetes wellness program. If you have diabetes and
do not participate in the wellness program, your costs may
be higher. For more information about the diabetes
wellness program, please contact: 1-855-449-2889
$5,400
This is not a cost
estimator.
Don’t use these examples to
estimate your actual costs under
this plan. The actual care you
receive will be different from these
examples, and the cost of that care
will also be different.
See the next page for important
information about these examples.
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
Page 7 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
Questions and answers about the Coverage Examples:
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What are some of the
assumptions behind the
Coverage Examples?
What does a Coverage Example
show?
Can I use Coverage Examples to
compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or treatment
isn’t covered or payment is limited.
Does the Coverage Example predict
my own care needs?
No. Treatments shown are just examples.
The care you would receive for this condition
could be different based on your doctor’s advice,
your age, how serious your condition is, and
many other factors.
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They are
for comparative purposes only. Your own costs
will be different depending on the care you
receive, the prices your providers charge, and
the reimbursement your health plan allows.
Yes. When you look at the Summary
of Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Yes. An important cost is the
premium you pay. Generally, the lower
your premium , the more you’ll pay in
out-of-pocket costs, such as
copayments, deductibles, and
coinsurance . You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible
spending arrangements (FSAs) or health
reimbursement accounts (HRAs) that
help you pay out-of-pocket expenses.
Are there other costs I should
consider when comparing
plans?
Does the Coverage Example predict
my future expenses?
Page 8 of 8
Questions: Call 1-855-449-2889 or visit us at chcflorida.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can
view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.
SNO:
1202018
SBC Name:
017_72600 017_15971 017_4051
