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Summary of Coverage

Summary of Coverage

PLAN E is a Medicare eligible preferred provider plan for persons under 65 that are enrolled in Medicare. The plan pays secondary to Medicare and has an annual deductible of $1,000.

PLANS B, C, D, F and G are preferred provider plans. These plans give you the option of choosing any provider but pay a higher percentage of allowed charges if you choose a provider who is part of the Midlands Choice Network. They offer a $1,000, $1,500, $2,500, $5,000 and $10,000 deductible. This plan is not available to Medicare eligible enrollees.
Check with your medical providers for their participation in the Midlands Choice PPO Network or call 1.800.605.8259, Prompt 3, to verify if your health care provider participates in the network. You can also review the Midlands Choice Provider network on this website. A copy of the Midlands Choice Provider directory is also available on request. (All network plan enrollees receive a directory with their medical plan contract document.)

This document is intended for descriptive purposes only. All benefits are subject to the terms, conditions, limitations, exclusions, deductibles, copayments, and any and all other contract provisons. Actual contract provisions prevail in the event of conflict with this document.

OUTLINE OF BENEFIT PLANS

  • PPO Plans
  • Carveout

    Footnotes

    [1] Semi-private or private if medically necessary
    [2] $20 copay applies when the service is not covered by Medicare
    [3] $100 copay applies when the service is not covered by Medicare