Coventry Gold $5 Copay POS Carelink - Tulsa Region (Oklahoma)

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Company Coventry Health Care of Kansas, Inc.
Plan Year 2014
State Oklahoma
Metal Tier Gold
Plan Type POS
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $1,750
Deductible (Family) $3,500
Coinsurance 20%
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctors Visits

Primary Care Visit $5
Specialist Visit $50
In Patient Hospital Services 20% Coinsurance after deductible
Emergency Room Services $250

Tests and Imaging

Imaging (CT/PET Scans, MRIs) $250 copay
Laboratory Outpatient and Professional Services 20% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance


Mental / Behavioral Health 20% coinsurance
Rehabilitative Speech Therapy 20% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance
Outpatient Facility $250 copay
Outpatient Surgery 20% coinsurance

Prescription Drugs

Generic Rx $5
Preferred Brand Rx $30 Copay after deductible
Non Preferred Brand Rx $60 Copay after deductible
Specialty Drugs 20% Coinsurance after deductible

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