ABG Business Associates, LTD.
"Dedicated to the health care needs of small business"

ATLANTIS HEALTH PLAN
POS Summary of Benefits - Plan A $20

Financial In Network Out of Network
Office Visit Copay $20 Subject to deductible & coinsurance
Deductible Single/Family $0 $1000/$2500
Coinsurance $0 70/30
Maximum of Out of Pocket
(After deductible)
Single/Family		 $0 $3000/$7500

 

Doctor Services In Network Out of Network
Office Visits PCP & Specialist $20 Subject to deductible & coinsurance
Inpatient Hospital Visit $0 Subject to deductible & coinsurance
Allergy Testing and Treatment $0 Subject to deductible & coinsurance
Anesthesia $0 Subject to deductible & coinsurance
Diagnostic services & treatments $20 per visit Subject to deductible & coinsurance
Mammography screening No cost Subject to deductible & coinsurance
Obstetrical/ Gynecological services $20 per visit Subject to deductible & coinsurance
Pap smears $20 per visit Subject to deductible & coinsurance
Second surgical opinion No cost You pay 0%, not subject to deductible
Periodic adult physical examinations $20 per visit In network benefits only
Well-child care visits (including immunizations) No cost In network benefits only
Pre & post natal care $20 per visit Subject to deductible & coinsurance
Delivery of child No cost Subject to deductible & coinsurance
Surgical services No cost Subject to deductible & coinsurance

 

Prescription Benefits In Network Out of Network
Generic 50% copay 50% copay
Brand Name Copay based on retail Copay based on retail
Non-formulary Cost of the prescription Cost of the prescription

 

Ambulatory Services In Network Out of Network
Radiation therapy and chemotherapy $20 per visit Subject to deductible & coinsurance
Hemodialysis $20 per visit Subject to deductible & coinsurance
Pre-admission testing $20 per visit Subject to deductible & coinsurance
X-ray and laboratory services $20 per visit Subject to deductible & coinsurance

 

Hospital Services In Network Out of Network
Inpatient admission (per continuous confinement) $250 copay Subject to deductible & coinsurance
Outpatient surgery facility charges No cost Subject to deductible & coinsurance
Blood and blood products No cost Subject to deductible & coinsurance
Ambulance services No cost Subject to deductible & coinsurance
Emergency room care (no admission to hospital) $50 copay per visit Subject to deductible & coinsurance

 

Hospital Alternatives In Network Out of Network
Skilled nursing facility: 45 days per calendar year No cost Subject to deductible & coinsurance
Home health care: 60 visits per calendar year No cost Subject to coinsurance only
Hospice care: inpatient (210 days combined with outpatient) No cost Subject to deductible & coinsurance
Hospice care: outpatient No cost Subject to deductible & coinsurance

 

Rehabilitative Services:
Physical/Speech/
Occupational		 In Network Out of Network
Inpatient: 30 days per diagnosis per calendar year No cost Subject to deductible & coinsurance
Outpatient: 20 visits per diagnosis per calendar year No cost Subject to deductible & coinsurance

 

Mental Health In Network Out of Network
Inpatient admission: 30 days per diagnosis per calendar year No cost Subject to deductible & coinsurance
Outpatient: 20 visits per  calendar year $25 copay per visit Subject to deductible & coinsurance

 

Substance Abuse In Network Out of Network
Inpatient detoxification limited to 7 days per calendar year No cost Subject to deductible & coinsurance
Outpatient: 60 visits per  calendar year (20 of the visits may be used for family therapy) $20 per visit Subject to deductible & coinsurance

 

Medical Equipment & Supplies In Network Out of Network
Durable medical equipment & supplies No cost Subject to deductible & coinsurance
Diabetic equipment & supplies $20 per item or 34-day supply Subject to deductible & coinsurance

 

LIFETIME MAXIMUM In Network Out of Network
  None $1,000,000

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