Summary of Benefits - Well Premium
Premium USA
Guaranteed Issue
States Available
AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, NE, NH, NJ, NV, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI, WV
States Not Available
AK, HI, MT, NM, NY, ND, PR, RI, SD, VT, WY
*Office visit copay for a "new" physician relationship or first time visiting a new doctor is $70 for Primary Care and $150 for Specialist.
**Lab & image copays are per image billed and per lab panel billed.
Please Note: Please refer to the Schedule of Benefits for the official list of Benefits Coverage, Limitations, and Exclusions. If plan comparison above differs from the Schedule of Benefits, the Schedule of Benefits will govern.
Please Note: Services performed at a hospital not related to inpatient hospitalization or surgery will not be covered. Any tests or imaging sent to a hospital by a physician or outpatient facility to be read or reviewed will not be covered. Member will be liable for 100% of the cost when this occurs. It is the members responsibility to first check with their provider to verify these services are not being sent to a hospital. This can be an issue for preventative mammograms, Member is advised to clarify with provider ahead of time.
Plan Change Rules: Once enrolled, dependents cannot be added until the policy until the aniversary date which is defined as an open enrollment period unless dependent has a qualifying SEP
NOTE: be sure to copy / paste www.FindVaultProviders.com when sending to a member to search the network because of the security feature attached requiring opt in to search the network.
