Your Insurance Agency

Licence Number: 000000
  Peter Weller
23341 Mission St.
Tracy, CA 95358
1 800 555-5555
service@jhpinsite.com
     
  Applicant Age:45
   
 Insurance Plan Summary
 All benefits are subject to deductible unless otherwise noted.

   
   
  SimpleChoice 25 MC 1500 Lumenos HSA 1500
    Estimated Monthly Premium: $214 00

Estimated Monthly Premium: $291 00 Estimated Monthly Premium: $358 00

In Network Benefits
 

  

 

 

 Plan Type   PPO  PPO HSA
Deductible    $2,500  $1500 deductible individual, $3000 family. $1500 individual, Family: $3000 aggregate. (All family member medical expenses that are subject to the plan deductible are combined.)
Office Visit Copay    Plan pays 100% after deductible.  $30 Non-specialist Office Visit (General Physician, Family Practitioner, Pediatrician, or Internist). $40 specialist. Plan pays 100% after deductible. (Deductible is waived for office visits related to preventive services. Office visits may also be paid with funds from the health incentive account.)
Coinsurance    Plan pays 100%  70/30 100% (Subject to deductible)
Maximum out of Pocket    $2500 (Includes deductible)  $6000 individual, $12,000 family. (Includes deductible) Plan pays 100% after deductible.
Lifetime Maximum    $6 million per covered person  $5 million per insured $5 million per covered person
Prescription drugs    $5 Generic, $35 Brand Name Formulary, $50 Non Formulary (A separate $250 calendar year deductible applies to brand name drugs.)  $15 generic, $30 brand name preferred, $50 non-preferred. (A $250 calendar year deductible per person, applies to all brand name drugs.) 100% after deductible is met.
Health Incentive Account         

Outpatient
  Emergency Room   100%  70% (Plus $100 copay) 100%
  Ambulance   100%  70% 100%
  Lab / X-rays   100%  70% 100%
  Outpatient Surgery   100%  70% 100%
  Maternity - Prenatal/Postnatal   Not covered  Not covered 100%
  Well Baby Care   You pay $25 copay. Deductible is waived (Newborns to age 18. Checkups, immunizations, vision and hearing exams.  70% 100% for nationally recommended services. Deductible is waived.
  Adult Preventive Care   You pay $25 copay. Deductible is waived. Coverage for yearly OB/GYN exam4 (breast and pelvic exams, pap smears and mammography), yearly prostate cancer screening and exam. Annual Routine Gyn Exam (Pap/Mammogram): No copay. Not subject to deductible. Annual Physical: $30 copay. Not subject to deductible ($200 per calendar year benefit maximum).   100% for nationally recommended services. Deductible is waived.
  Physical Therapy   100% (20 visit maximum per calendar year.) See product brochure See product brochure
  Chiropractic / Acupuncture / Acupressure   50% (12 visit maximum per calendar year. $20 maximum payable per visit.) See product brochure See product brochure
  Mental Health Office Visits   See product brochure See product brochure See product brochure
  Home Health Care   See product brochure 70% (Limited to 30 visits per calendar year) See product brochure
           

Inpatient
  Hospitalization   100% 70% 100%
  Maternity   Not covered Not covered 100%
  Mental Health   See product brochure See product brochure See product brochure
           

Additional Information
  Optional Benefits  
  • Dental
  • Vision
  • Term Life
  
  • Dental
  Items of note      
  • The Lumenos HIA plan is designed to empower you to take control of your health as well as the dollars you spend on your health care. This plan gives you the benefits of a typical health plan plus the opportunity to earn health care dollars to help offset your out-of-pocket health expenses by taking certain steps to improve your health.
 

Out-of-Network Benefits
      The costs when using non-preferred providers is considerably higher than when you use preferred providers. You will have to pay any part of a provider's bill which is over what Health Net allows in benefits for non-preferred providers. Coverages are usually reduced to 50%. Some benefits (such as preventive care), are not covered at all. The annual out-of-pocket maximum is increased to $10,000 (including deductible). See product brochure for more information.  The costs when using out-of-network providers is considerably higher than when you use in-network providers. You will have to pay any part of a provider's bill which is over what Aetna allows in benefits for out-of-network providers. Coverages are usually reduced to 50% . There is a separate out-of-network deductible and a separate coinsurance maximum. See product brochure for more information. The costs when using out-of-network providers is considerably higher than when you use in-network providers. You will have to pay any part of a provider's bill which is over what Blue Cross allows in benefits for out-of-network providers. Coinsurance is reduced to 70%. The out-of-pocket maximum is double the in-network amount, and is tallied separately. Additional limitations apply. Please see plan brochure for details.
           

Disclaimer
           
     
  Plan Brochure
  Plan Brochure
Plan Brochure
This information is for casual plan comparison only. Though we endeavor to be accurate, we cannot guarantee the above outline to be a flawless representation of benefits.  Evidence of coverage and plan contracts should be consulted for a detailed description of benefits and limitations.  Company brochures are either available online, or mailed upon request.