Covenant Advantage (HMO-POS) Plans in Your Area

Covenant Advantage
(HMO-POS)
Covenant Advantage Plus
(HMO-POS)
Medical & Hospital
Monthly Premium$0$25
Maximum Out-of-Pocket Limit$3,800 Per Year$3,800 Per Year
Annual Deductible$0$0
Preventative Care/Screenings$0 Copay$0 Copay
Primary Care Physician Visits$5 Copay$5 Copay
Specialist Doctor Visits$30 Copay$30 Copay
NEW for 2021!No referrals for in-network specialist visits!
Urgent Care$60 Copay$60 Copay
Emergency Care$90 Copay$90 Copay
Lab Services$10 Copay$10 Copay
Home Health Care100% Coverage100% Coverage
Chiropractic Care$20 Copay$20 Copay
Inpatient Hospital$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital$150 Copay$150 Copay
Outpatient Surgery at Ambulatory Surgery Center$100 Copay$100 Copay
Part D Prescription Drug Coverage
Annual Deductible
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
Tier 1
Preferred Generic
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $5 Copay
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $5 Copay
Tier 2
Non-Preferred Generics
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $10 Copay
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $10 Copay
Tier 3
Preferred Brand Names
  • Preferred Pharmacies - $40 Copay
  • Other Network Pharmacies - $45 Copay
  • Preferred Pharmacies - $40 Copay
  • Other Network Pharmacies - $45 Copay
Tier 4
Non-Preferred Brand Names
  • Preferred Pharmacies - $90 Copay
  • Other Network Pharmacies - $95 Copay
  • Preferred Pharmacies - $90 Copay
  • Other Network Pharmacies - $95 Copay
Tier 5
Specialty Drugs
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
Initial Coverage Limits
  • Preferred Pharmacies - $4,130 Per Year
  • Other Network Pharmacies - $4,130 Per Year
  • Preferred Pharmacies - $4,130 Per Year
  • Other Network Pharmacies - $4,130 Per Year
What Medications are Covered
Extra Benefits
Vision Care
  • $25 Copay for routine eye exam
  • $0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
  • $25 Copay for routine eye exam
  • $0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
Preventive Dental Care$0 Copay (two visits per calendar year)
  • $0 Copay (two visits per calendar year)
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
Comprehensive Dental CareNot Covered
  • $100 Deductible
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
Over-the-Counter (OTC) Items
  • $50 Per Quarter
  • Up to 2 orders per quarter; no rollovers
  • $75 Per Quarter
  • Up to 2 orders per quarter; no rollovers
Hearing
  • $25 Copay for hearing exam
  • $1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
  • $25 Copay for hearing exam
  • $1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
Transportation Assistance$0 Copay for 20 one-way trips to approved locations per year$0 Copay for 30 one-way trips to approved locations per year
Fitness MembershipSilverSneakers® included at no costSilverSneakers® included at no cost
Travel BenefitsEmergency or urgent care coverage if you are making a trip out of state or countryEmergency or urgent care coverage if you are making a trip out of state or country
New for 2021!
Post-Hospitalization Meal Benefit
28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)
Covenant Advantage
(HMO-POS)
Covenant Advatange Plus
(HMO-POS)
Medical & Hospital
Monthly Premium
$0$25
Maximum Out-of-Pocket Limit
$3,800 Per Year$3,800 Per Year
Annual Deductible
$0$0
Preventive Care/Screenings
$0 Copay$0 Copay
Primary Care Physician Visits
$5 Copay$5 Copay
Specialist Doctor Visits
$30 Copay$30 Copay
NEW for 2021!
No referrals for in-network specialist visits!
Urgent Care
$60 Copay$60 Copay
Emergency Care
$90 Copay$90 Copay
Lab Services
$10 Copay$10 Copay
Home Healthcare
100% Coverage100% Coverage
Chiropractic Care
$20 Copay$20 Copay
Inpatient Hospital Care
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital
$150 Copay$150 Copay
Outpatient Surgery at Ambulatory Surgery Center
$100 Copay$100 Copay
Part D Prescription Drug Coverage
Annual Deductible
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
Tier 1
Preferred Generic
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $5 Copay
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $5 Copay
Tier 2
Non-Preferred Generics
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $10 Copay
  • Preferred Pharmacies - $0 Copay
  • Other Network Pharmacies - $10 Copay
Tier 3
Preferred Brand Names
  • Preferred Pharmacies - $40 Copay
  • Other Network Pharmacies - $45 Copay
  • Preferred Pharmacies - $40 Copay
  • Other Network Pharmacies - $45 Copay
Tier 4
Non-Preferred Brand Names
  • Preferred Pharmacies - $90 Copay
  • Other Network Pharmacies - $95 Copay
  • Preferred Pharmacies - $90 Copay
  • Other Network Pharmacies - $95 Copay
Tier 5
Specialty Drugs
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
Initial Coverage Limits
  • Preferred Pharmacies - $4,130 Per Year
  • Other Network Pharmacies - $4,130 Per Year
  • Preferred Pharmacies - $4,130 Per Year
  • Other Network Pharmacies - $4,130 Per Year
What Medications are Covered
Extra Benefits
Vision Care
  • $25 Copay for routine eye exam
  • $0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
  • $25 Copay for routine eye exam
  • $0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
Preventive Dental Care
  • $0 Copay (two visits per calendar year)
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
  • $0 Copay (two visits per calendar year)
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
Comprehensive Dental Care
Not Covered
  • $100 Deductible
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
Over-the-Counter (OTC) Items
  • $50 Per Quarter
  • Up to 2 orders per quarter; no rollovers
  • $75 Per Quarter
  • Up to 2 orders per quarter; no rollovers
Hearing
  • $25 Copay for hearing exam
  • $1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
  • $25 Copay for hearing exam
  • $1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
Transportation Assistance
$0 Copay for 20 one-way trips to approved locations per year$0 Copay for 30 one-way trips to approved locations per year
Fitness Membership
SilverSneakers® included at no costSilverSneakers® included at no cost
Travel Benefits
Emergency or urgent care coverage if you are making a trip out of state or countryEmergency or urgent care coverage if you are making a trip out of state or country
New for 2021! Post-Hospitalization Meal Benefit
28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)

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