McAllen Health Insurance

from East Coast Health Insurance

Health-Insurance-Quotes

Aetna Texas Health Insurance Plans

McAllen, Texas had its population explode from just over 100,000 people in 2000 to over 700,000 by 2007. While this is an interesting stat, it is not what makes McAllen unique. What makes this border town unique is that it is the second most expensive town in America for Health Care. This is an oddity that is even harder to explain given that the county it is in, Hidalgo, has the lowest household income average in the country. In 2006, Medicare spent around $15,000 per person in the county, which is nearly twice the national average. The reason for this appears to be that in McAllen, people are heavily treated and tested when they see a doctor for a health issue. Looking at the Medicare stats, in every category, McAllen doctors went crazy with treatments and tests, and received a large percentage more of every treatment than what the average is. It seems that instead of using their knowledge to treat patients, doctors are simply running them through a battery of tests, most unnecessary, and that has caused the price of insurance to skyrocket.

McAllen Texas Health Insurance Scenario Premium Cases

To find quotes for just what insurance does cost in McAllen, Texas, I used the same scenario I always use across the board: I searched for a 34-year-old male shopping for a Texas health insurance policy. I tried to get a $2500 deductible and a total maximum out of pocket or exposure of $4500 including both the deductible and coinsurance costs.  Some companies are at $5000 but realistically only 2 -3% of people pass this exposure per year so the $5000 shouldn’t be a factor. The health insurance assumptions for this example include up front office visit copays, in other words you pay a copay not a deductible to go to the doctor’s office.  The same applies to prescription coverage in this McAllen Health Insurance example.

Below we ran some sample health insurance quotes for McAllen, Texas health insurance comparison samples.  I used a $2500 deductible and and tried to keep the plan as similar as possible for the sake of comparison. In this case Humana wins the award for the most coverage for the least money, however it is not as simple as that due to the fact that the Unicare and Blue Cross plan might offer more copay benefits before reaching the calender year deductible.  Of course for every demographic in every zip code and every family size type there is a different winner.  And to further complicate things each company offers nearly 100 plans, except Cigna in Texas who only offer 20!

The best thing to do is run a Texas health insurance quote and to then let us explain the plans available to you in your particular zip code as to further complicate the issue there is the fact that certain Texas health insurance plans are not available in every region.

Health Insurance Report

Name:
Effective Date: 10/15/2009
Applicant: Male, 34, Non Smoker

State: TX       Zip: 78501

Quotes Prepared By: Jeremy Ehrenthal
Company: East Coast Health Insurance
Email: jehrenthal@hotmail.com
Phone: 888-803-5917
Fax: 954.571.4143

Compare Plans

Company Plan Type Deductible Coinsurance Copay Premium

Portrait Share 80 Plus Rx Unlimited

 PPO $2,500 20% $35

$138.66

Monthly Cost

Apply

Company Plan Type Deductible Coinsurance Copay Premium

Unicare FIT 2500 Plan

 PPO $2,500 25% $30

$164.00

Monthly Cost

Apply

Company Plan Type Deductible Coinsurance Copay Premium

Select Blue Advantage Plan V

 PPO $2,500 15% $25

$171.00

Monthly Cost

Apply
Company Plan Type Deductible Coinsurance Copay Premium

Copay Select United Health Care

 Network $2,500 20% $35

$187.97

Monthly Cost

Apply

Company Plan Type Deductible Coinsurance Copay Premium
Aetna Texas health insurance plans

Aetna PPO 2500 Texas

 PPO $2,500 20% $30

$197.00

Monthly Cost

Apply

Company Plan Type Deductible Coinsurance Copay Premium

Cigna Open Access 2000

 PPO $2,000 20% $25

$213.00

Monthly Cost

Apply

(I)=Individual (F)=Family (P)=Preferred (S)=Standard

Health Insurance Report

Name:
Effective Date: 10/15/2009
Applicant: Male, 34, Non Smoker

State: TX       Zip: 78501

Quotes Prepared By: Jeremy Ehrenthal
Company: East Coast Health Insurance
Email: jehrenthal@hotmail.com
Phone: 888-803-5917
Fax: 954.571.4143

Plan Detail

Insurance Plan Detail

Apply
Portrait Share 80 Plus Rx Unlimited
Apply Humana Texas Health Insurance Application
Estimated Monthly Premium $138.66
Plan Type PPO
Networks

Plan Details

Copay

 Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.N/A

Deductible

 $2,500 (Two members must meet their deductible).$5,000 (Two members must meet their deductible).

Coinsurance

 80%60%

Coinsurance Limit

 Maximum Out-of-Pocket Expense Limit: $2,000 Individual and $4,000 Family.Maximum Out-of-Pocket Expense Limit: $8,000 Individual and $16,000 Family.

Out-of-Pocket Maximum

 Maximum Out-of-Pocket Expense Limit: $2,000 Individual and $4,000 Family.Maximum Out-of-Pocket Expense Limit: $8,000 Individual and $16,000 Family.

Lifetime Maximum

 $5,000,000 per covered person

Annual Maximum

 see brochure

Office Visit
  • Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.60% after deductible
    		•

    Prescription Drugs
  • $500 prescription drug deductible per individual.
  • 100% after Copayments (up to 30-day supply):
    • Level One (lowest copayment for lowest cost generic and brand-name drugs)- $15 copayment is not subject to prescription drug deductible.
    • Level Two (higher copayment for higher cost generic and brand-name drugs)- $35 copayment after prescription drug deductible.
    • Level Three (higher copayment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic equivalents in Levels One or Two)- $55 copayment after prescription drug deductible.
    • Level Four (highest copayment for high-technology drugs)- 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year.
  • Mail Order (90-day supply)- 100% after three times the retail copayment.
  • $500 prescription drug deductible per individual.
  • 70% after Copayments (up to 30-day supply):
    • Level One (lowest copayment for lowest cost generic and brand-name drugs)- $15 copayment is not subject to prescription drug deductible.
    • Level Two (higher copayment for higher cost generic and brand-name drugs)- $35 copayment after prescription drug deductible.
    • Level Three (higher copayment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic equivalents in Levels One or Two)- $55 copayment after prescription drug deductible.
    • Level Four (highest copayment for high-technology drugs)- 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year.
  • Mail Order (90-day supply)- 70% after three times the retail copayment.
    		•

    Emergency Room

    		 80% after $75 copayment per visit and deductible (copayment waived if admitted).60% after $75 copayment per visit and deductible (copayment waived if admitted).

    Adult Preventive Care
  • Routine annual physical exam- 80% (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
  • Routine Pap smears (age 18 and older) (Age and/or frequency limits apply)- 80%
  • Routine mammograms- 80% (Age and/or frequency limits apply)
  • Routine lab, pathology and X-ray- 80% after deductible (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
  • Routine annual physical exam- 60% after deductible (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
  • Routine Pap smears (age 18 and older) (Age and/or frequency limits apply)- 60% after deductible
  • Routine mammograms- 60% after deductible (Age and/or frequency limits apply)
  • Routine lab, pathology and X-ray- 60% after deductible (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
    		•

    Child Preventive Care
  • Routine immunizations (birth to age 6)- 100%
  • Routine immunizations (age 6 to age 18)- 80% (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
  • Routine immunizations (birth to age 6)- 100%
  • Routine immunizations (age 6 to age 18)- 60% after deductible (Benefit payable after 90-day waiting period for preventive care and 30 day waiting period for mental health, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)
    		•

    Lab/X-ray

    		 see brochure

    Maternity

    		 Complications of pregnancy and sick baby services- 80% after deductible.Complications of pregnancy and sick baby services- 60% after deductible.

    Physical Therapy

    		 see brochure

    Skilled Nursing

    		 80% after deductible (up to 30 days per calendar year).60% after deductible (up to 30 days per calendar year).

    Home Health Care

    		 80% after deductible (up to 60 days per calendar year).60% after deductible (up to 60 days per calendar year).

    Mental Health
  • Inpatient and Outpatient care (Combined $2,500 per calendar year maximum.
  • Outpatient care not to exceed $500 of the $2,500 calendar year maximum.)- 75% after deductible.
  • Inpatient and Outpatient care (Combined $2,500 per calendar year maximum.
  • Outpatient care not to exceed $500 of the $2,500 calendar year maximum.)- 50% after deductible.
    		•

    Hospital Care

    		 80% after deductible60% after deductible

    Included Benefits

    		 see brochure

    Optional Benefits

    		 Dental

  • Prescription drug, no deductible
  • Lifetime maximum benefit
  • $500 Supplemental Accident Benefit
  • $1,000 Supplemental Accident Benefit
    		•

    Fees

    		 see brochure

    Note

    		 see brochure

    Policy Form Number

    		see brochure

    Included Riders

    Product Brochure

    		 see brochure

    Plan Detail

    Insurance Plan Detail

    Apply
    Enhanced FIT 2500 Plan
    Apply Texas Health Insurance Application
    Estimated Monthly Premium $164.00
    Plan Type PPO
    Networks

    Plan Details

    Copay

    		 $30 copay, deductible waived for unlimited visits50% after deductible

    Deductible

    		 $2,500, two-member family maximumAdditional $2,000 out of network deductible per member, per year

    Coinsurance

    		 75% after deductible50% after deductible

    Coinsurance Limit

    		 Annual Out of Pocket Maximum (includes copays, except pharmacy copays) $3,000 plus deductible per member, $6,000 plus deductible per familyAnnual Out of Pocket Maximum (includes copays, except pharmacy copays) $10,000 plus deductible per member, $20,000 plus deductible per family

    Out-of-Pocket Maximum

    		 (includes copays, except pharmacy copays) $3,000 plus deductible per member, $6,000 plus deductible per family(includes copays, except pharmacy copays) $10,000 plus deductible per member, $20,000 plus deductible per family

    Lifetime Maximum

    		 $5 million per member

    Annual Maximum

    		 see brochure

    Office Visit

    		 All medical office visits, exams and diagnostic x-ray and lab work performed on the same date and during the same office visit for any covered illness or injury – $30 copay, deductible waived for unlimited visits50% after deductible

    Prescription Drugs
  • Retail Pharmacies (30-day supply):
    • Generic (Deductible waived): $10 copay
    • Brand Name Drugs ($250 Brand Name Deductible applies): $30 copay for formulary drugs, or a $50 copay for nonformulary drugs
    • Self Injectable Drugs (Brand Name Deductible applies to brand name self-administered injectable drugs): UniCare pays 75% after brand-name deductible.
  • Retail Pharmacies (30-day supply):
    • Generic (Not subject to deductible): UniCare pays 50% of the average wholesale price
    • Brand Name Drugs ($250 Brand Name Deductible applies): UniCare pays 50% of the average wholesale price
    • Self Injectable Drugs (Brand Name Deductible applies to brand name self-administered injectable drugs): UniCare pays 50% of the average wholesale price
    		•

    Emergency Room
  • Outpatient Medical Emergency Room Treatment- Unicare pays 100% after $100 copay
    		•

    Adult Preventive Care

    		 (Age 18 and over)

  • Pap Smear, Mammogram, PSA screening- 100% (deductible waived) to a maximum of $500, then 80% after deductible
  • Office visit- $30 copay (deductible waived), unlimited visits(Age 18 and over)
  • Pap Smear, Mammogram, and PSA screening- 50% after deductible
  • Office visit- 50%, unlimited visits (deductible applies to most services)
    		•

    Child Preventive Care
  • Well Baby/Children Care (To age 18):
    • Immunizations: 100% deductible waived
    • Offive Visits- $30 copay (deductible waived), unlimited visits
    • Routine Care- 100% (deductible waived) to a maximum of $500, then 75% coinsurance after deductible
  • Well Baby/Children Care (To age 18):
    • Immunizations- 100% (deductible waived)
    • Office visits- 50% after deductible
    • Routine Care- 50% after deductible
    		•

    Lab/X-ray
  • Lab and X-ray- 75% after deductible
  • Diagnostic Lab and X-ray- 50% after deductible
    		•

    Maternity

    		 Not covered

    Physical Therapy
  • Physical/Occupational Therapy and Acupuncture- Subject to deductible and coinsurance (Maximum payment of $30 per visit, up to 12 visits per member, per year for all of these services combined).
    		•

    Skilled Nursing
  • Subject to deductible adn coinsurance (Limited to a maximum covered expense of $400 per day, and 100 days per year).
    		•

    Home Health Care
  • Subject to deductible and coinsurance (Limited to a combined maximum of 60 visits each year).
    		•

    Mental Health
  • Inpatient- Subject to deductible and coinsurance (paid up to $100 per day, up to a maximum payment of $3,000 per year).
  • Outpatient- Subject to deductible and coinsurance (payable up to $30 per visit up to a maxium of 12 visits per year).
    		•

    Hospital Care

    		 75% after deductible50% after deductible

    Included Benefits

    		 see brochure

    Optional Benefits

    		 see brochure

    Fees

    		 see brochure

    Note

    		 see brochure

    Policy Form Number

    		see brochure

    Included Riders

    Product Brochure

    		 see brochure

    Plan Detail

    Insurance Plan Detail

    Apply
    Select Blue Advantage – Plan V
    Apply Texas Health Insurance Plans
    Estimated Monthly Premium $171.00
    Plan Type PPO
    Networks

    Plan Details

    Copay

    		 $25None

    Deductible

    		 $2,500 Individual/$7,500 Family$5,000 Individual/$15,000 Family

    Coinsurance

    		 85% of the Allowable Amount for Eligible Expenses75% of the Allowable Amount for Eligible Expenses

    Coinsurance Limit

    		 $3,000 Individual/$6,000 Family$6,000 Individual/$12,000 Family

    Out-of-Pocket Maximum

    		 see brochure

    Lifetime Maximum

    		 $5,000,000

    Annual Maximum

    		 see brochure

    Office Visit

    		 $25 office visit copay includes same day lab and x-ray, up to annual max of $750Physician office visits subject to deductible and coinsurance

    Prescription Drugs

    		 $3,000 Calendar Year maximum for each Participant. Copayment is $10 for Generic Drug, $30 for Preferred Brand Name Drug, $45 for Non-Preferred Brand Name Drug. Copayment is based on 30-day supply on each occasion dispensed. 90-day supply requires three separate Copayment Amounts.

    Emergency Room

    		 Facility Charges: 85% of Allowable Amount after $100* Copayment and Calendar Year Deductible (*Waived if admitted to Hospital immediately following the visit)
    Physician Charges: 85% of Allowable Amount after Calendar Year Deductible

    Adult Preventive Care
  • 100% of Allowable Amount subject to Physician office visit Copayment. $300 Calendar Year maximum.
  • 75% of Allowable Amount after Calendar Year Deductible.
    		•

    Child Preventive Care
  • 100% of Allowable Amount after Physician office visit Copay Amount. $300 Calendar Year maximum.
  • Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8.
  • 75% of Allowable Amount after Calendar Year Deductible.
    		•

    Lab/X-ray

    		 85% of allowable amount after calendar year deductible75% of Allowable Amount after Calendar Year Deductible

    Maternity

    		 see brochure

    Physical Therapy

    		 see brochure

    Skilled Nursing
  • 100% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
  • 75% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•

    Home Health Care
  • 100% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
  • 75% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•

    Mental Health

    		 Not Covered

    Hospital Care

    		 85% of Allowable Amount after Calendar Year Deductible75% of Allowable Amount after Calendar Year Deductible

    Included Benefits

    		 see brochure

    Optional Benefits

    		 see brochure

    Fees

    		 see brochure

    Note

    		 see brochure

    Policy Form Number

    		see brochure

    Included Riders

    Product Brochure

    		 see brochure

    Plan Detail

    Insurance Plan Detail

    Apply
    Copay Select
    Apply United Health Care Texas Health Insurance Plans
    Estimated Monthly Premium $187.97
    Plan Type Network
    Networks

    Plan Details

    Copay

    		 see brochure

    Deductible

    		 $2,500 (maximum 2 per family, per calendar year)

    Coinsurance

    		 80%

    Coinsurance Limit

    		 $15,000

    Out-of-Pocket Maximum

    		 $3,000 per covered person after deductible and copays

    Lifetime Maximum

    		 $3 million per covered person

    Annual Maximum

    		 see brochure

    Office Visit

    		 Office Visit – History and Exam: $35 copay – no deductible ($25 Copay plan enhancement available)

    Prescription Drugs
  • Tier 1 – $15 copay, no deductible; Tier 2-4 – combined $200 deductible per person, per calendar year, then: Tier 2 – $35 copay, Tier 3 – $65 copay, Tier 4 – you pay 25% coinsurance (If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price)
  • Annual Maximum: $3,000 covered expense, per person, per calendar year (No Annual Max. plan enhancement available)
    		•

    Emergency Room
  • Illness: You pay: $100 copay if not admitted, then chosen coinsurance after deductible
  • Injury: You pay: chosen coinsurance after deductible
    		•

    Adult Preventive Care
  • Doctor Office Visit: $35 copay (3-month waiting period, not subject to deductible)
  • X-ray and lab: You pay: chosen coinsurance (in conjunction with the preventive office visit, performed in the doctor’s office or a network facility, 3-month waiting period, not subject to deductible)
  • Preventive Mammogram, Pap Smear, PSA screening: You pay: chosen coinsurance (not subject to deductible or waiting period)
    		•

    Child Preventive Care
  • Doctor Office Visit: $35 copay (3-month waiting period, not subject to deductible)
  • Child Immunizations (0-18): You pay: chosen coinsurance (3-month waiting period, not subject to deductible)
    		•

    Lab/X-ray

    		 Outpatient X-ray and lab: You pay: chosen coinsurance after deductible (performed in the doctor’s office or a network facility)

    Maternity

    		 Optional Benefit

    Physical Therapy

    		 see brochure

    Skilled Nursing

    		 see brochure

    Home Health Care

    		 see brochure

    Mental Health

    		 You pay: chosen coinsurance after deductible (Limited benefit)

    Hospital Care

    		 You pay: chosen coinsurance after deductible

    Included Benefits

    		 see brochure

    Optional Benefits

    		 see brochure

    Fees

    		 see carrier specific disclaimers

    Note

    		 see brochure

    Policy Form Number

    		see brochure

    Included Riders

    Product Brochure

    		 see brochure

    Plan Detail

    Insurance Plan Detail

    Apply
    PPO 2500
    Apply Texas Health Insurance Application
    Estimated Monthly Premium $197.00
    Plan Type PPO
    Networks

    Plan Details

    Copay

    		 Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay, deductible waived (Unlimited visits); Specialist Visit: $40 copay, deductible waived (Unlimited visits)Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)

    Deductible

    		 Individual: $2,500, Family: $5,000Individual: $5,000, Family: $10,000

    Coinsurance

    		 80% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)50% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied)

    Coinsurance Limit

    		 Individual: $2,500, Family: $5,000Individual: $5,000, Family: $10,000

    Out-of-Pocket Maximum

    		 Individual: $5,000, Family: $10,000 (Includes deductible)Individual: $10,000, Family: $20,000 (Includes deductible)

    Lifetime Maximum

    		 $5,000,000 per insured (Maximum applies to combined in and out-of-network benefits)

    Annual Maximum

    		 N/A

    Office Visit

    		 Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $30 copay (Unlimited visits); Specialist Visit: $40 copay (Unlimited visits)Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 70% after deductible (Unlimited visits); Specialist Visit: 70% after deductible (Unlimited visits)

    Prescription Drugs

    		 Pharmacy Deductible: $500 per insured (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay, deductible waived; Preferred Brand (Oral Contraceptives Included): $35 copay after deductible; Non-Preferred Brand (Oral Contraceptives Included): $60 copay after deductible; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $2,500 per insuredPharmacy Deductible: $500 per insured (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay plus 70%, deductible waived; Preferred Brand (Oral Contraceptives Included): $35 copay plus 70% after deductible; Non-Preferred Brand (Oral Contraceptives Included): $60 copay plus 70% after deductible; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $2,500 per insured

    Emergency Room

    		 $100 copay (waived if admitted), 80% coinsurance after deductible

    Adult Preventive Care

    		 Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap/Mammogram): $0 copay, deductible waived; Preventive Health – Routine Physical (Aetna will pay up to $200 per exam, Maximum applies to combined in and out-of-network benefits, No waiting period): $30 copay, deductible waived (Includes lab work and X-rays)Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap/Mammogram): 70% after deductible; Preventive Health – Routine Physical (Aetna will pay up to $200 per exam, Maximum applies to combined in and out-of-network benefits, no waiting period): 70% after deductible (Includes lab work and X-rays)

    Child Preventive Care

    		 $30 copay (Age and frequency schedule apply)70% after deductible (Age and frequency limits apply).

    Lab/X-ray

    		 80% after deductible50% after deductible

    Maternity

    		 Not covered (Except for pregnancy complications)

    Physical Therapy

    		 Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 80% after deductible (Aetna will pay up to $25 per visit max.)Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 50% after deductible (Aetna will pay up to $25 per visit max.)

    Skilled Nursing

    		 80% after deductible (in lieu of hospital, 30 days per calendar year, Maximum applies to combined in and out-of-network benefits)50% after deductible (in lieu of hospital, 30 days per calendar year, Maximum applies to combined in and out-of-network benefits)

    Home Health Care

    		 80% after deductible (in lieu of hospital, 30 days per calendar year, Maximum applies to combined in and out-of-network benefits)50% after deductible (in lieu of hospital, 30 days per calendar year, Maximum applies to combined in and out-of-network benefits)

    Mental Health

    		 Not covered except for severe, biologically based mental or nervous disorders and associated treatment of drug and alcohol dependencies.

    Hospital Care

    		 Hospital Admission: 80% after deductible; Outpatient Surgery: 80% after deductible; Urgent Care Facility: $50 copay, deductible waivedHospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: 50% after deductible

    Included Benefits

    		 see brochure

    Optional Benefits

    		 Individual Dental PPO Max Plan

    Fees

    		 see brochure

    Note

    		 see brochure

    Policy Form Number

    		see brochure

    Included Riders

    Product Brochure

    		 see brochure

    Plan Detail

    Insurance Plan Detail

    Apply
    Open Access 2000
    Apply Cigna Texas Health Insurance Application
    Estimated Monthly Premium $213.00
    Plan Type PPO
    Networks

    Plan Details

    Copay

    		 Primary Care Physician – $25, Specialist – $50CIGNA pays 60% after plan deductible

    Deductible

    		 Individual: $2,000, Family: $4,000Individual: $4,000, Family: $8,000

    Coinsurance

    		 CIGNA pays 80% after plan deductibleCIGNA pays 60% after plan deductible

    Coinsurance Limit

    		 N/A

    Out-of-Pocket Maximum

    		 Individual: $3,000, Family: $6,000Individual: $6,000, Family: $12,000

    Lifetime Maximum

    		 $5,000,000 in- and out-of-network combined

    Annual Maximum

    		 N/A

    Office Visit

    		 Primary Care Physician – $25, Specialist – $50CIGNA pays 60% after plan deductible

    Prescription Drugs
  • Brand Name Prescription Drug Deductible – $250 per member, per year (Does not apply to Generic)
  • Pharmacy Brand Name Calendar Year Maximum – $5,000 per member, per year
  • Retail Pharmacy:
    • Generic/Preferred Brand Name/Non-preferred Brand Name – $10/$35/$60
    • Self Injectables – CIGNA pays 70% after plan deductible
  • Mail Order Pharmacy:
    • Generic/Preferred Brand Name/Non-preferred Brand Name – $25/$85/$150
    • Self Injectables – CIGNA pays 70% after plan deductible
  • Brand Name Prescription Drug Deductible – $250 per member, per year (Does not apply to Generic)
  • Pharmacy Brand Name Calendar Year Maximum – $5,000 per member, per year
  • Retail Pharmacy:
    • Generic/Preferred Brand Name/Non-preferred Brand Name -CIGNA pays 50% after plan deductible
    • Self Injectables – CIGNA pays 50% after plan deductible
  • Mail Order Pharmacy:
    • Generic/Preferred Brand Name/Non-preferred Brand Name -Not covered
    • Self Injectables – Not covered
    		•

    Emergency Room
  • Hospital Emergency Room – $100 Additional Deductible, Plan deductible then CIGNA pays 80% (Additional Deductible waived if admitted to hospital)
  • Ambulance – CIGNA pays 80% after plan deductible (Maximum payment of $3,000 per year, Emergency Transport only)
  • Urgent Care Services – CIGNA pays 80% after plan deductible
  • Hospital Emergency Room – $100 Additional Deductible, plan deductible then CIGNA pays 80% if true emergency (Additional Deductible waived if admitted to hospital); otherwise CIGNA pays 60% after plan deductible
  • Ambulance – CIGNA pays 80% after plan deductible if true emergency; otherwise, CIGNA pays 60% after plan deductible (Maximum payment of $3,000 per year, Emergency transport only)
  • Urgent Care Services – CIGNA pays 80% after plan deductible if true emergency; otherwise, CIGNA pays 60% after plan deductible
    		•

    Adult Preventive Care
  • Adult Preventive Care (age 7 and up):
    • Primary Care Physician – $25
    • Specialist – $50
    • Lab Work, Immunizations,Flu Shot – CIGNA pays 100% up to a maximum payment of $300 per calendar year
    • Mammogram, Pap Smear, PSA, Colorectal Cancer Screening – CIGNA pays 100%, deductible waived
  • Office visit, Lab Work, Immunizations,Flu Shot – CIGNA pays 60% up to a maximum payment of $300 per calendar year
  • Mammogram, Pap Smear, PSA, Colorectal Cancer Screening – CIGNA pays 60% after deductible
    		•

    Child Preventive Care
  • Children Through Age 6
    • Office Visit – $25
    • Specialist – $50
    • Lab Work, Routine Screenings – CIGNA pays 100% up to a maximum payment of $300 per calendar year
    • Immunizations – CIGNA pays 100%,plan deductible waived
  • Children Through Age 6:
    • Office Visit – CIGNA pays 60%, plan deductible waived
    • Lab Work, Routine Screenings – CIGNA pays 60%, plan deductible waived up to a maximum payment of $300 per calendar year
    • Immunizations – CIGNA pays 100%, deductible waived
    		•

    Lab/X-ray

    		 CIGNA pays 80% after plan deductibleCIGNA pays 60% after plan deductible

    Maternity

    		 Not covered

    Physical Therapy

    		 Physical Therapy, Speech Therapy (only for children with Developmental Delays and 3 years old or younger), & Occupational Therapy – CIGNA pays a maximum of $40 per visit after plan deductible (Maximum 24 visits per member, per year, in- and out-of-network combined)Physical Therapy, Speech Therapy (only for children with Developmental Delays and 3years old or younger), & Occupational Therapy – CIGNA pays a maximum of $40 per visit after plan deductible (Maximum 24 visits per member, per year, in- and out-of-network combined)

    Skilled Nursing

    		 CIGNA pays $400 maximum payment per day after plan deductible (Maximum 100 days per member, per year, in- and out-of-network combined)CIGNA pays $400 maximum payment per day after plan deductible (Maximum 100 days per member, per year, in- and out-of-network combined)

    Home Health Care

    		 CIGNA pays 80% after plan deductible (Maximum 60 visits per member, per year, in- and out-of-network combined)CIGNA pays 60% after plan deductible (Maximum 60 visits per member, per year, in- and out-of-network combined)

    Mental Health
  • Inpatient – CIGNA pays $200 maximum payment per day after plan deductible (Maximum benefit of $3,000 per calendar year)
  • Outpatient – CIGNA pays $30 maximum per visit, after plan deductible (Maximum 24 visits per member, per year for both in-and out-of-network)
  • Inpatient – CIGNA pays $200 maximum payment per day after plan deductible (Maximum benefit of $3,000 per calendar year)
  • Outpatient – CIGNA pays $30 maximum per visit, after plan deductible (Maximum 24 visits per member, per year for both in-and out-of-network)
    		•

    Hospital Care

    		 Inpatient Hospital Services – CIGNA pays 80% after Plan deductibleInpatient Hospital Services – CIGNA pays 60% after Plan deductible

    Included Benefits

    		 N/A

    Optional Benefits

    		 N/A

    Fees

    		 N/A

    Note

    		 N/A

    Policy Form Number

    		N/A

    Included Riders

    Product Brochure

    		 see brochure

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