Coventry Gold $5 Copay POS Carelink - Tulsa Region OK

Plan Information
Company Coventry Health Care of Kansas, Inc.
State OK
Metal Tier Gold
Plan Type POS

Cost Sharing Benefits

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.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $1,750 $6,400
Deductible (Family) $3,500 $12,800
Coinsurance 20% 50%
Out of Pocket Maximum (Individual) $5,000 $0
Out of Pocket Maximum (Family) $10,000 $0
Services In Network Out of Network
Primary Care Visit $5 50% coinsurance
Specialist Visit $50 50% coinsurance
In Patient Hospital Services 20% Coinsurance after deductible 50% coinsurance
Emergency Room Services $250 First three visits: $250 copay
Mental / Behavioral Health 20% coinsurance 50% coinsurance
Imaging (CT/PET Scans, MRIs) $250 copay 50% coinsurance
Rehabilitative Speech Therapy 20% coinsurance 50% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance 50% coinsurance
Preventative Care $0 50% coinsurance
Laboratory Outpatient and Professional Services 20% coinsurance 50% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance 50% coinsurance
Outpatient Facility $250 copay 50% coinsurance
Outpatient Surgery 20% coinsurance 50% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx $5
Preferred Brand Rx $30 Copay after deductible
Non Preferred Brand Rx $60 Copay after deductible
Specialty Drugs 20% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

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