Page 4 - Comparative-Benefits-STM-Plans
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the duration of the plan. If making more than authorized copay visits to doctor’s office, you pay for the visit at the rate contract rate of the doctor with
the insurance company if doctor is in its PPO. [Preferred Physician Organization].
Deductible:
Individual: The selected deductible amount must be paid by the insured person before the plan benefit begins. The deductible applies per
covered person, per covered period. To be risk averse, use choice of least deductible amount for the plan, though the premium will be
higher.
Family: When three covered persons in a family each satisfy their deductible, the deductibles for any remaining covered family members
are considered satisfied for the remainder of the coverage period. For all three plans, there is no family deductible.
Coinsurance percentage and Out-of-Pocket maximum
After the deductible maximum amount has been met, you pay the selected coinsurance percentage of covered expenses until the out-of-
pocket maximum that you selected has been reached.
The out-of-pocket maximum amount is specific to expenses applied to the coinsurance percentage. it does not include covered
expenses applied to the deductible, precertification penalty amounts, or expenses not covered under the policy.
Once the deductible and Out-of-Pocket maximum amount has been satisfied, additional covered expenses within the coverage period are
paid to by insurance at 100 percent, not to exceed the covered period maximum benefit amount. Benefits maximums to certain items may
also apply. Please read your policy.
Age Eligibility
Primary applicant: age 18 to 64
Spouse: age 18 to 64
Dependent Children: up to age 26
Child only plan: age 2 to 18
Restriction of Benefits on Pre-existing Condition : A general statement
A pre-existing condition is defined as any medical condition or sickness for which medical advice, care, diagnosis, treatment, consultation or medication
was recommended or received from a doctor within five years** immediately preceding the covered persons’ effective date of coverage; or symptoms
within the five years** immediately prior to the coverage that would cause a reasonable person to seek diagnosis, care or treatment will not be a
covered benefit. Consultation means evaluation, diagnosis, or medical advice was given with or without the necessity of a personal examination or visit.
the insurance company if doctor is in its PPO. [Preferred Physician Organization].
Deductible:
Individual: The selected deductible amount must be paid by the insured person before the plan benefit begins. The deductible applies per
covered person, per covered period. To be risk averse, use choice of least deductible amount for the plan, though the premium will be
higher.
Family: When three covered persons in a family each satisfy their deductible, the deductibles for any remaining covered family members
are considered satisfied for the remainder of the coverage period. For all three plans, there is no family deductible.
Coinsurance percentage and Out-of-Pocket maximum
After the deductible maximum amount has been met, you pay the selected coinsurance percentage of covered expenses until the out-of-
pocket maximum that you selected has been reached.
The out-of-pocket maximum amount is specific to expenses applied to the coinsurance percentage. it does not include covered
expenses applied to the deductible, precertification penalty amounts, or expenses not covered under the policy.
Once the deductible and Out-of-Pocket maximum amount has been satisfied, additional covered expenses within the coverage period are
paid to by insurance at 100 percent, not to exceed the covered period maximum benefit amount. Benefits maximums to certain items may
also apply. Please read your policy.
Age Eligibility
Primary applicant: age 18 to 64
Spouse: age 18 to 64
Dependent Children: up to age 26
Child only plan: age 2 to 18
Restriction of Benefits on Pre-existing Condition : A general statement
A pre-existing condition is defined as any medical condition or sickness for which medical advice, care, diagnosis, treatment, consultation or medication
was recommended or received from a doctor within five years** immediately preceding the covered persons’ effective date of coverage; or symptoms
within the five years** immediately prior to the coverage that would cause a reasonable person to seek diagnosis, care or treatment will not be a
covered benefit. Consultation means evaluation, diagnosis, or medical advice was given with or without the necessity of a personal examination or visit.
