Announcing the New CoventryOne Fusion POS
Low Cost Georgia Health Insurance Plans


Authorized CoventryOne Agent*



CoventryOne Fusion POS Low Cost Health Insurance In-Network Benefit Summary**
(click here for out-of-network benefit summary)

Description of Health Insurance Benefits

$3,000 Deductible
100% / 50% Plan

$5,000 Deductible
100% / 50% Plan

Lifetime Maximum Per Member

$6,000,000

$6,000,000

Deductible Per Member Per Benefit Year
(3 maximum per family )

$3,000

$5,000

Out-of-Pocket Maximum Per Benefit Year

Plan pays 100%
after deductible is met

Plan pays 100%
after deductible is met

Medical benefits shown below with copays are not subject to the deductible. Coinsurance percentages are effective after the deductible has been met unless specifically noted
Physicians Services - (PCP and Specialists)
-Office Visits
- X-ray and Lab when performed in office
-Immunizations
-Allergy Testing and Treatment
-Preventive Health Screenings

First 6 Visits $30 Copay
7+ Visits: Not Covered

First 6 Visits $30 Copay
7+ Visits: Not Covered
Mammograms (No Deductible - In Network)

 Covered at 100% - no copay

 Covered at 100% - no copay
Emergency Room Care Medical Emergency
or Serious Accidental Injury
(Non emergency use of the emergency
room is not a covered benefit)

$150 copay then 100% coverage
(copay waived if admitted)

$150 copay then 100% coverage
(copay waived if admitted)
Urgent Care Center (In or Out of Network)

$55 copay

$55 copay
Ambulance Service

$150 copay

$150 copay
Inpatient Hospital Services

Plan pays 100% after deductible

Plan pays 100% after deductible
Maternity

NOT COVERED

NOT COVERED
Outpatient Hospital / Facility - X-ray, Lab, Diagnostic
Services - Surgery Anesthesia - Chemotherapy
- Radiation Treatment

Plan pays 100% after deductible

Plan pays 100% after deductible
Short Term Therapies (20 visits per benefit year)
Physical/Occupational/Speech
Respiratory Therapy, Cardiac and Pulmonary Rehabilitation
Developmental Delay is not covered

Plan pays 100% after deductible

Plan pays 100% after deductible
 Chiropractic Services(12 visits per benefit year)
Care must be received from ActivHealth Provider

$10 

$10 
Durable Medical Equipment, Prosthetics and Orthoses
($2,500 max per benefit year)

Plan pays 100% after deductible

Plan pays 100% after deductible
Transplants

Plan pays 100% after deductible

Plan pays 100% after deductible
Home Health Care -(30 days per benefit year)

Plan pays 100% after deductible

Plan pays 100% after deductible
Skilled Nursing Facility -(30 days per benefit year)

Plan pays 100% after deductible

Plan pays 100% after deductible
Hospice

Plan pays 100% after deductible

Plan pays 100% after deductible
Prescription Drugs*

-Tier 1 - Preferred Generic (No Deductible)

-Tier 2 - Preferred Formulary (Deductible)

-Tier 3 - Non Preferred Brand and a few non Preferred Generic (Deductible)

-Tier 4 - Self Injectable Drugs (Deductible)

*$2,000 deductible must be satisfied before copay applies
on Tiers 2, 3, & 4
Retail must be obtained from Participating Pharmacies only (except for Emergency), and mail order must be obtained from Caremark
To determine the specific cost of your medication,
please refer to the Drug Formulary

Retail:

$10

$35

$50

70%
  Mail Order*:
$10

$70

$150

Not Covered

*93 Day Supply

Retail:

$10

$35

$50

70%
  Mail Order*:
$10

$70

$150

Not Covered

*93 Day Supply
Dental
-One preventive cleaning every six months*

-Diagnostic & resorative services, orthodontic and emergency care*
*All care must be received as an established patient of a DeltaCare provider

$20 Copay

Various Copays
and Discounts

$20 Copay

Various Copays
and Discounts
Vision - one exam every 12 months
(Exam must be received from an Avesis provider)

$15 Copay

$15 Copay
All medical benefits (except Mammograms) subject to benefit year deductible unless specifically noted with a copay. Benefit limitations are a combination of in-network and out-of-network benefits. Deductibles and copays do not apply to out-of-pocket maximum.
All plans are subject to a twelve (12) month waiting period for pre-existing conditins except when a condition is disclosed on the application at the time of medical underwriting and the policy is approved. Preexisting condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care of treatment, or a condition for which medical advice or treatment was recommended by or received from a provider of health care services within 12 months preceding the effective date of coverage of the insured.

An optional Mental Health Rider is available with POS plans shown above. If this Rider is purchased, it must be taken by all family members applying for coverage on the same application. Each member is charged an additional monthly premium. All care must be coordinated through American Psych Systems. Refer to your broker for more details.

**This summary is a partial description of coverage and does not detail all benefits, limitations and exclusions. Please consult the Member Contract, Schedule of Benefits, and applicable Riders to determine the exact terms, conditiions and scope of coverage. Ask your broker for a DeltaCare dental provider list created specifically for the CoventryOne product.
(As with all insurance providers, not disclosing known prexisting conditions could result in termination of your benefits)
CoventryOne is an individual product underwritten by Coventry Health Care of Georgia, Inc.


(Adobe Acrobat reader is necessary to download Application. Click here to download the free Adobe Acrobat reader )

Click here to have an enrollment kit mailed or e-mailed to you (be sure to specify which plan you're interested in)


9 Dunwoody Park
Suite 136
Atlanta, GA 30338

Call Holly, Chris or Bob at
(770) 396-9517
Outside of the Atlanta area,
call toll-free: 1-877-711-8376.
fax: 770-396-4318
Email: holly@insurance-now.com