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ALPHA CARE GOLD HEALTH PLAN
 

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SERVICE TYPE IN-NETWORK OUT-OF-NETWORK
CALENDAR YEAR DEDUCTIBLE   $500, 1000, 2,000, 3000, 5000 $1000, 2,000, 3000, 4,000, 6, 000  
(MAXIMUM 3X FAMILY) (WITH CO-PAY/DRUG CARD) (WITH CO-PAY/DRUG CARD)  
   
        $250 (NO CO-PAYS/DRUG CARD) $500 (NO CO-PAYS/DRUG CARD)
OUT-OF POCKET PER CAL YR   PLAN 1 - $500, 1,000, 2,000 $2,000, 4,000, 8,000    
(2X FAMILY PLUS DEDUCTIBLE)   PLAN 2 - $1,000, 2,000, 4,000 $2,500, 5,000, 10,000  
COINSURANCE PERCENTAGES PLAN 1 - 90%   60%      
        PLAN 2 - 80%   50%      
PHYSICIAN OFFICE     PLAN 1 - $25   DEDUCTIBLE+CO-INS  
INCLUDES X-RAY & LAB PLAN 2 - $35 DEDUCTIBLE+CO-INS  
DIABETES SUPPLIES * IN-NETWORK OV 100% AFTER  
ALLERGY INJECTIONS CO-PAY UP TO $200 MAXIMUM  
CAT SCANS, MRI'S EXCESS SUBJECT TO DEDUCTIBLE  
        AND CO-INSURANCE        
HOSPITAL SERVICES - INPATIENT $150 CO-PAY   $300 CO-PAY    
  DEDUCTIBLE + CO-INS DEDUCTIBLE + CO-INS  
   
HOSPITAL SERVICES - EMERGENCY $50 CO-PAY $50 CO-PAY  
        DEDUCTIBLE + CO-INS DEDUCTIBLE + CO-INS  
OTHER COVERED CHARGES   DEDUCTIBLE + CO-INS DEDUCTIBLE + CO-INS  
UNLESS OTHERWISE INDICATED              
ADULT PREVENTATIVE SERVICES CO-PAY $200 MAXIMUM DEDUCTIBLE + CO-INS  
UPS PRESCRIPTION DRUG CARD TIER 1 - $2 CO-PAY FOR GENERIC        
FOUR TIER FORMULARY TIER 2 - $15 CO-PAY FOR COST EFFECTIVE BRAND  
30 DAY MAXIMUM SUPPLY OR 20%, WHICHEVER IS GREATER  
90 MAIL ORDER SUPPLY TIER 3 - $30 CO-PAY FOR HIGH COST BRAND DRUGS  
  OR 30%, WHICHEVER IS GREATER  
  TIER 4 - MEMBER PAYS THE COST DIFFERENCE  
  BETWEEN GENERIC DRUG AND MULTIPLE SOURCE  
  BRAND DRUGS REGARDLESS OF EITHER MEMBER  
        OR PHYSICIAN REQUEST        
2 MILLION LIFETIME MAXIMUM ORGAN TRANSPLANT LIFETIME MAXIUM $250,000
DME 20% CO-PAY PHYSICAL THERAPY CALENDAR YEAR MAXIMUM $2,500
THIS IS ONLY A BRIEF DESCRIPTION OF BENEFITS AVAILABLE AND ALL COVERED SERVICES ARE NOT
LISTED. ALL ELIGIBLE SERVICES ARE SUBJECT TO THE DEDUCTIBLE AND CO-INSURANCE WITH THE EXCEPTION
OF THE COVERED IN-NETWORK OFFICE VISIT. THE OFFICE VISIT CO-PAY IS SUBJECT TO A $200 MAXIMUM
AND THE DIFFERENCE IS THEN APPLIED TO THE DEDUCTIBLE AND CO-INSURANCE.
ALPHA DATA SYSTEMS, INC.
1545 WEST MOCKINGBIRD LANE, STE 6000 DALLAS, TX 75235 PHONE - 214-638-1488 FAX 214-638-1653

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