| Benefit | COVA Care - You Pay | COVA HDHP - You Pay |
| Deductible One Person Two or more persons |
$225 $450 |
$1,750 $3,500 |
| Out-of-Pocket Expense Limit One Person Two or more persons |
$1,500 $3,000 |
$5,000 $10,000 |
| Doctor's Visits Primary Care Physician Specialist |
$25 $40 |
20% coinsurance after deductible has been met |
| Hospital Services Inpatient Outpatient |
$300 per stay $125 per visit |
20% coinsurance after deductible has been met |
| Emergency Room visits | $125 per visit (waived if admitted) |
20% coinsurance after deductible has been met |
| Outpatient diagnostic laboratory tests, shots, and x-rays |
20% coinsurance after deductible has been met |
20% coinsurance after deductible has been met |
| Prescription Drugs Mandatory Generic Retail Pharmacy Tier One Tier Two Tier Three Tier Four (Specialty Drugs) Home Deliver Pharmacy Tier One Tier Two Tier Three Tier Four (Specialty Drugs) Diabetic test strips & glucose monitors |
Up to 34-day supply $15 $25 $40 $50 90-day supply $30 $50 $80 $100 20% (no deductible) |
20% coinsurance after deductible has been met 20% coinsurance after deductible has been met 20% (after deductible) |
| Behavioral Health and EAP Inpatient Treatment Medical Professional Visit Non-Medical Professional Visit EAP (up to 4 visits per incident) |
$300 per stay $25 $25 $0 |
20% coinsurance after deductible has been met 20% coinsurance after deductible has been met $0 |
| Wellness Services Well Child - through age 6 Office visits at specified intervals Immunizations, lab and x-rays Routine Wellness - age 7 and older Annual checkup visit Primary Care Physician Specialist Immunizations, lab, & x-rays Preventative Care* One each per year - specific age limits |
$0 $0 $0 $0 $0 $0 |
$0 $0 $0 $0 $0 $0 |
| Dental Benefit Plan Year Deductible Plan maximum payment Diagnostic and preventative Primary Services Complex Restorative Orthodontics |
$50 single $100 dual $150 family $2000 per person/per year $0 - Two visits/year (no deductible) 20% coinsurance after deductible has been met See optional expanded Dental See optional expanded Dental |
$50 single $100 dual $150 family $2000 per person/per year $0 - (no deductible) 20% coinsurance after deductible has been met 50% coinsurance after deductible has been met 50% coinsurance - no deductible ($2000 lifetime max) |
* Includes gynecological exam, Pap test, mammography screening, prostate exam (digital rectal exam), prostate specific antigen test (PSA), and colorectal cancer screening.
COVA Care Additional Coverage Options
| Benefit | Who Pays | Administrator |
Out - Of - Network May be combined with Expanded Dental or Vision, Hearing and Expanded Dental. Applies to Medical and Behavorial Health Services. |
Plan payment is reduced by 25%. You pay applicable deductible, co-payment and/or coinsurance. Provider may balance bill for amount above allowable charge. |
Anthem Value Options |
Expanded Dental May be combined with Out-of-Network. Plan pays up to $2,000 per member per plan year for Basic & Complex Services. Complex Restorative (inlays, onlays, crowns, dentures, and bridgework) Orthodontics $2,000 lifetime maximum per member |
You Pay - 50% coinsurance after deductible You Pay - 50% coinsurance, no deductible |
Delta Dental |
Vision, Hearing and Expanded Dental May be combined with Out-of-Network Vision Routine eye exam (every 24 months) Eyeglass Frames (every 24 months) Lenses (every 24 months) Plastic single vision (pair) Plastic bifocal (pair) Plastic trifocal (pair) Contact Lenses Hearing Routine hearing exam (48 mos.) Purchase of hearing aids and other related hearing services. ($1200 benefit max. every 48 months) Expanded Dental |
In Network You Pay $40 copay $100 allowance - then 20% off $20 copay then covered in full $20 copay then covered in full $20 copay then covered in full See allowance schedule In Network You pay $40 You pay $0 See above |
Anthem Blue View Anthem Delta Dental |
