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My HEALTH USA PPO2500 Plan
SUMMARY OF BENEFITS, ENROLLMENT FORM / APPLICATION AND BANKING
AUTHORIZATION
OPEN ENROLLMENT FIXED LOW MONTHLY RATES ARE AS FOLLOWS:
INDIVIDUAL $299.00
MEMBER +1 $449.00
FAMILY $529.00
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
• $5000.00 Max Per Occurrence
• Guaranteed Issue to individuals & small groups
• Physicians or Specialist Office Visit $25 Co-Pay
• Unlimited surgical benefits (80/20)
• Low Deductible $200
• Multi Plan PPO Network
• Stable & Locked Rates
• Available in most states
• HIPAA Compliant
• Fully insured
• No participation requirements for groups
IMPORTANT: These rates can only be guaranteed through Friday. We must have your information entered into the
system by the close of business in order to honor the rates quotes above. Please fax in the completed enrollment form
or contact a representative to be enrolled. Your effective date will be 1 st 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
Fax 888.814.9977
Please refer to your email to speak with your My Health USA representative.
My HEALTH USA
SUMMARY OF BENEFITS
PPO Network for Physicians &Hospitals
Our nationwide PPO Network allows you to choose your own doctors and hospitals. You will not need referrals for specialist visit. Feel free to ask a plan specialist to look up doctor information if needed.
Medical – $25 Co-Pay
At the time of the office visit, the provider will collect $25 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. No per occurrence maximums
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. No per occurrence maximums
Hospitalization/ Intensive Care
Your policy will provide coverage for any hospitalization or ICU. The coverage includes 80/20 coverage to plan maximum per occurrence with a $200 deductible. Hospital admission and a $400 per day benefit for up to 30 days per hospital confinement. If the per occurrence plan maximum is met. No per occurrence maximums
Accidental Medical Coverage $25,000
64% of hospital admissions are due to an accident. In the case of needed accidental medical occurrences patient will be covered for coverage up to $25,000 with a $1,000 deductible. Policy will include benefits for ongoing treatments as necessary. No per occurrence maximums
Accidental Death & Dismemberment
Your policy will provide $10,000 in benefits to you or your family.
ER / Ambulance service
Your policy will provide Emergency Room Coverage for any visits as a result of a sickness/accident. The coverage includes 80/20 coverage to plan maximum per occurrence with a $250 deductible. Deducible waived due to accident or admitted.
Prescriptions Drugs 50% Co-pay
50% co-pay for name brand or generic medications up to the maximum per member per year benefit. Member also receives Express Scripts discount card. All discounts and savings done at time of service no claim forms to file.
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. The coverage includes 80/20 coverage to plan maximum per occurrence with a $200 deductible.
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 $200 deductible
* Some benefits vary based plan schedule 2500 /5000 / 7500
*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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