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MY HEALTH USA PPO 300 Plan
SUMMARY OF BENEFITS, ENROLLMENT FORM / APPLICATION AND BANKING
AUTHORIZATION
OPEN ENROLLMENT FIXED LOW MONTHLY RATES ARE AS FOLLOWS:
INDIVIDUAL $169.00
MEMBER +1 $229.00
FAMILY $299.00
Included you will find plan highlights, a summary of benefits, enrollment form/application and a banking
authorization. Please review these benefits and contact your representative at 888.933.9449 or complete the
application and fax it back to us at 888.814.9977 or email to your representative listed on this page.
Plan Highlights
• First Dollar Coverage
• Guaranteed Issue to individuals & small groups
• Physicians or Specialist Office Visit No Co-Pay
• Unlimited surgical benefits
• No Deductible
• Multi Plan PPO Network
• Stable & Locked Rates
• Available in most states
• HIPAA Compliant
• Fully insured
• No participation requirements for groups
IMPORTANT: Your effective date will be 1st or the 15th of the next month for this plan. Note: This enrollment
form guarantees you acceptance through these benefits. Please feel free to call for details or to answer any questions
you may have.
Best Regards,
My Health USA
Director of Healthcare Sales
Phone 888.933.9449 Option 2
Fax 888.814.9977
www.myhealthusa.com
My HEALTH USA
SUMMARY OF BENEFITS
Medical – No Co-Pay
At the time of the office visit, the provider will collect $0 from the patient. (Primary, Specialist, or Chiropractor) Our nationwide Network allows you to choose your own doctors and hospitals. You will not need referrals for specialist visit. Feel free to ask a sales representative to look up doctor information if needed.
Dental
This will cover up to 60% on dental expenses. All routine visits, cleanings, cosmetic and elective procedures will be eligible for reduced rates based on the PPO schedule.
Hospitalization
Your policy will provide coverage for any hospitalization. The coverage includes a $300 hospital admission and a $300 per day benefit for up to 30 days per hospital confinement. Example: Day one, $600; five days, $1800
Intensive Care - $30,000
Your policy will provide $600 per day, for any ICU Confinement, Up to 30 days, Up to $18,300 per hospital confinement.
Accidental Injury Coverage
Emergency room and accidental occurrences will be covered for coverage up to $25,000 after deductible.
Policy will include benefits for ongoing treatments as necessary. With $50,000 accidental death benefit included.
Accidental Death & Dismemberment
Your policy will provide $5,000 in benefits to you or your family.
Emergency Room Sickness
Your policy will provide Emergency Room Coverage for any visits as a result of a sickness.
Prescriptions Drugs Rx Card Co-Pay
AWP less 16% discount then a 50% co pay per prescription up to an annual benefit per member. No pre-existing exclusions
Wellness Benefits
This policy provides benefits for annual physical exams, lab exams, lab test and diagnostic procedures.
Diagnostic Lab & X-Ray
Included benefits for lab work (glucose, urinalysis, CBM, blood tests), X Ray (chest and broken bones) and Advanced Studies such as EEG, EKG, CT scan, MRI, Mammograms, cancer screenings and PSA. Coverage provided at nearly every major lab in the US, over 7000 facilities available.
Vision and Hearing Benefits
The optical savings plan will provide savings of 15-50% off the regular retail price of eyeglasses, contact lenses, sunglasses and corrective surgery (Lasik, RKP, etc) at over 10,000 centers nationwide.
Other Medical Services
Your policy will provide coverage for Mental Health, Alcohol and Drug Rehabilitation in patient only, as well as Home Health Care, Hospice, Physical Therapy, and Durable Medical Equipment. 80/20 coverage to plan maximum per occurrence with a $300 deductible
* Some benefits vary based plan schedule 300//500 /1000
*Please read entire fulfillment pack and certificates for complete coverage, details, discounts and exclusions.
* 12 month pre existing clause on hospitalization and surgery schedule
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