| Copay
Plan through Coventry Health Care
Look into the Copay Plan.
- What is the Copay
Plan
- Available
Services
- How to Use the Copay
Plan
What is the
Copay Plan?
The Copay Plan is administered by Coventry Health Care and
uses The Coventry Health Care National Network of providers.
With this plan you have network and non-network benefits.
Available
Services
The Copay Plan through Coventry Health Care features:
- The freedom to choose care from any primary care physician,
specialist or hospital.
- No referrals.
- Specific copayments for most services.
- Non-network benefits.
When services are received from non-network providers, deductible
and coinsurance amounts apply. Non-network charges are limited
to the usual, customary and reasonable charges (UCR), unless
otherwise indicated. You may have to file your own claims
and pay higher out-of-pocket costs if you use non-network
providers. Claims for network services are filed for you.
Complete benefits for the Copay Plan are in HMO
& Copay Plan Benefits.
If you require covered services which are not available through
a network provider in your area, the claims may be paid at
80/20 rather than 70/30. Contact Coventry
Health Care to have a local provider approved prior to
receiving services. Keep in mind that approval granted for
a provider is not permanent. It may be granted per condition
only and for a specific amount of time.
The deductible is waived and claims are paid at 80/20 rather
than 70/30 for:
- Home health care.
- Infusion.
- Durable Medical Equipment (DME).
- Audiologists.
If you receive treatment in a network hospital or facility,
certain types of services such as physician, radiology, emergency,
anesthesiology and pathology are sometimes performed by non-network
providers. Expenses for these services are paid as network
benefits and are not subject to UCR.
| SAMPLE OF BENEFITS |
| You
Pay |
Network |
Non-Network |
| Deductible |
| Individual |
N/A |
$500 |
| Family |
N/A |
$1,000 |
| Office Visit |
$25 copayment |
30% coinsurance* |
| Hospital (inpatient) |
$300 copayment per admission |
30% coinsurance* |
| Lab & X-Ray |
100% coverage |
30% coinsurance* |
| Maternity |
$25 copayment for initial visit |
30% coinsurance* |
| Preventive
Care |
100% coverage |
30% coinsurance* |
| Outpatient
Surgery |
$75 copayment |
30% coinsurance* |
*Non-network
coinsurance amounts apply after your deductible has
been met. |
How to Use
the Copay Plan
There are no deductibles when using network providers. If
using non-network providers, you must meet a deductible before
claims are paid. You are also responsible to pay a specific
copayment or coinsurance amount on most medical services.
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