CoreGuard 3500 1 Member
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| In Network | Out of Network | |
| Annual Deductible | Individual: $3,500 Family: $7,000 | Individual: $3,500 Family: $7,000 |
| Annual Out-Of-Pocket Limit | Individual: $3,500 Family: $7,000 (Deductible not Included) | Individual: $7,500 Family: $15,000 (Deductible not Included) |
| Lifetime Maximum | $4,000,000 (In and Out of Network combined) | $4,000,000 (In and Out of Network combined) |
| Office Visits | 50% | 70% |
| Prescription Drugs | Tier 1: $15 Tier 2: $35 ($2,000 Deductible/member for Tier 2) | Not Covered |
| Laboratory and Radiology | 50% | 70% |
| Annual Physical Exam | $25/$75 Co-Pay at HealthyCheck Centers for Basic/Premium Screening | Not Covered |
| Annual OB-GYN Exam | 50% | 50% |
| Well Baby Care | See Brochure | See Brochure |
| Outpatient Surgery | 50% | 70% |
| Emergency Room | 50% | 50% |
| Ambulance | See Brochure | See Brochure |
| Home Health Care | See Brochure | See Brochure |
| Mental Health Services - Outpatient | See Brochure | See Brochure |
| Chiropractic Care | See Brochure | See Brochure |
| Acupuncture / Acupressure | Not Covered | Not Covered |
| Inpatient Hospital | 50% | 70% |
| Maternity Care | Covered | Covered |
| Mental Health - Inpatient | See Brochure | See Brochure |
| Chemical Dependency | See Brochure | See Brochure |
IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.
Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!
Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.
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