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North Carolina A guide for individuals and families

North Carolina
A guide for
and families
CoventryOne® is an individual product (for individuals and families) offered by Coventry Health Care, an Aetna company.
The health insurance benefits you want, at a cost you can afford
Visit for more information.
80.02.351.1-NC (1/15)
Things to think about when choosing your 2015 health
benefits and insurance plan*:
How your health care needs may be changing. Maybe you’re planning to add to your
family. Or maybe you had major surgery this year and expect next year to be less
eventful! Planning ahead can help you find the right balance between your monthly
payment and what you’ll pay out of pocket.
The total cost for your plan. When comparing your plan options, make sure you’re
looking at more than just the monthly payment (also called premium). Take a close
look at the plan benefits too. Look for terms like “copay” and “deductible.” These
will tell you what you could pay for your care when you go to the doctor, pick up a
prescription, or have a hospital stay.
Who is in your plan’s network. Networks can be different depending on the plan
you pick. Even plans offered by the same insurance company could have different
networks with different hospitals and doctors. Check that all your doctors are in
your plan’s network before choosing a plan.
*Your insurance company may automatically enroll you in the same plan, or a similar plan, for 2015. You can change your plan during Open Enrollment.
Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the
administration of the plan, including enrollment and benefit determinations.
CoventryOne health benefits and insurance products are underwritten by Coventry Health Care of the Carolinas, Inc.
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Table of Contents
Intro to Coventry The Coventry Advantage
Important terms you should know
Choosing your plan
Choosing your benefits
Choosing a provider
CoventryOne provider networks
Getting the health care benefits you need
Prescription drug program
Apply beginning November 15, 2014
Eligibility and requirements
Exclusions and limitations
Simple and Affordable | 3
an Aetna company
Local health plan
National strength
Coventry has provided health insurance benefits coverage
for more than 25 years. We’re proud of our relationships
with the community and our members, and we look
forward to serving you.
Aetna (NYSE: AET) is one of the nation’s leading diversified
health care benefits companies, serving an estimated 45
million people with information and resources to help them
make better informed decisions about their health care.
Aetna offers a broad range of traditional, voluntary and
consumer-directed health insurance products and services,
including medical, pharmacy, dental, behavioral health,
group life and disability plans, and medical management
capabilities, Medicaid health care management services,
workers’ compensation administrative services and health
information technology services.
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Whether you need a little coverage
or a lot, CoventryOne is right for
you with:
• Affordable plan options that can help you meet
your needs
• Valuable extras that help keep your costs down
• Online tools for easy access
• Friendly, efficient customer service
You’re covered when you
need care
Our plans include all the Essential Health Benefits,
such as:
Doctor’s office visits, hospital and outpatient care
Preventive care for adults and children
Prescription drugs (including a mail-order program)
Routine gynecological exams including Pap tests
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Thank you for your interest
in CoventryOne health plans
You can select a product at You can
work with a broker. You can also shop
on the health insurance marketplace
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The Coventry Advantage
Extras to help you get more from your health plan
Support for your well-being
Helpful online tools
Secure online tools help you get the information you need,
when you need it:
We’re committed to supporting our members’ health
and wellness. That’s where Coventry WellBeingSM
comes in. You’ll have access to:
Check claims status
Request or print a new ID card
Order prescription refills
Research costs for drugs, procedures and conditions
Find a doctor at
And much, much more.
Coventry® Mobile
While on the go, our mobile app gives you health
information at your fingertips. With the app, you can:
• Check the status of a medical claim and view a
detailed summary
• View your current benefits usage details
• Verify your doctor is in-network
• Locate a hospital or urgent care center near you
• View your ID card, current medications, allergy and
immunization details, family history and more — and
email or fax this information to your health care provider
• Online health management. This program offers
tips for getting in shape, eating right and living well.
You can use it to customize your fitness, nutrition
and life skills goals.
• Health risk assessments. We offer online health
risk assessments for common conditions such as high
blood pressure and heart disease. After you answer
some questions we’ll tell you whether you’re at risk
for developing these conditions. If you are, we’ll offer
suggestions for how to reduce your risk.
• Email reminders for tests, screenings and
immunizations. It can be easy to forget about
preventive care. You can sign up online for email
reminders about scheduling screening tests and
when to get certain vaccines.
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Important terms you should know.
Shopping for insurance may be new for you. Here are some important
terms to keep in mind while you shop for coverage.
Health insurance exchange
A service, medical supply or drug that health insurance
helps pay for. Some examples are doctor visits, tests
and X-rays.
The health insurance exchange (or marketplace) is a new
way to shop for health insurance. Online stores help you
find, compare and choose a health insurance plan that fits
your needs.
The amount you pay after meeting your yearly deductible.
For example, if you have an X-ray after you’ve met your
deductible for the year, we’ll pay most of the allowed amount,
and you’ll pay a certain percentage of it. The percentage
you pay is called coinsurance. This is a form of cost sharing.
It’s a specified percentage you must pay for covered
health services.
Copay (copayment)
A set cost you pay when you receive a covered service.
Most plans have copays for doctor visits. You pay your
copay to the physician or other health care provider.
Cost sharing
You pay a share of the costs for services through your
deductible, coinsurance and copays. This doesn’t include
your monthly payment. The percentage you pay is based on
the plan level you choose.
The set amount you pay each year before we pay any
benefits, unless otherwise stated.
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Out of pocket
The total amount you pay for covered services — including
copays, deductibles and coinsurance.
The set amount you pay each month for your health
insurance coverage.
Provider network
A group of health care providers that works with us to offer
services to our members at a discounted price. In-network
benefits apply when you receive care from physicians or
facilities that are part of our network.
Utilization management
Services that help you get the right care from the right
doctor at the right time.
Choosing your plan
What do POS and HMO mean?
Point of service (POS) plans cover both in
network and out-of-network care. But you get
the highest level of coverage when you get care
in network.
Health maintenance organization (HMO) plans
provide coverage for in network and emergency
out-of-network care.
Out-of-network benefits are not available for HMO
plans, except for emergency care.
If you enroll in a Health Maintenance Organization
(HMO) plan, you must select a primary care
physician (PCP) to manage your care.
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Choosing your benefits
Choosing your level of benefits
Family premium pricing
Most plans offered will include metal levels in the
plan name — gold, silver and bronze. The metal level
does not reflect the quality of the plan. The metal level
relates to how much you pay in monthly payments versus
out-of-pocket costs. For example, if you choose a silver
plan, you will pay more each month compared to a bronze
plan, but have a lower out-of-pocket cost when visiting
your doctor.
Your monthly payment will be the total of the rates for each
person on the plan, based on their age and tobacco use.
We will only charge you for your three oldest dependents
under the age of 21.
Catastrophic plans
People under the age of 30 and some people with limited
incomes may buy a catastrophic health plan. These plans
offer lower monthly payments. Your out-of-pocket costs for
deductibles, copays and coinsurance are generally higher.
To qualify for a catastrophic plan, you must be under
30 years old or get a hardship exemption.
Native American
If you’re a Native American, you may qualify for low-cost
or no-cost health insurance coverage. Our Native
American plans are available on the exchange. Visit to see if you’re eligible and enroll.
Health savings account (HSA) with bronze
deductible-only plan
If you choose the bronze deductible-only plan, you have
the option of selecting an HSA administered through our
partner, HealthEquity®.
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Premium subsidies
You may qualify for help making your monthly payments.
Help is based on the size of your family and your income.
You can view the chart at
Purchasing your plan from the health
care exchange?
You can work with a broker or apply online at Please call us at
1-855-449-2889 – 8 a.m. to 8 p.m. ET
(for exchange plans).
Choosing a provider
Choose a primary care physician (PCP) to
manage your health
A primary care physician (PCP) knows you and your
medical history best. They’ll coordinate your care and help
you get the most from your health benefits. A PCP handles
preventative care, as well as common medical conditions.
If you enroll in a Health Maintenance Organization (HMO)
plan, you must select a primary care physician (PCP) to
manage your care.
A specialist is a doctor who is an expert in a certain kind of
disease or injury. If you see a specialist, check to see if he/
she is in the plan’s network.
Find a plan with the right network of doctors and
hospitals to meet your needs
Network providers – they are easy to find
It’s important to know which doctors and hospitals are part
of your network. You can find this information online.
• Doctors, hospitals and other medical providers, go
to and select “Find a Doctor.”
• Pharmacies, go to and
select “Find a Pharmacy.” For preferred pharmacies,
it will say, “Preferred for up to one month supply only.”
• Mental health or substance abuse providers,
go to and register as a
new user or log in to find a provider.
• Pediatric vision care providers, go to
and enter your ZIP code under “Find a VSP doctor.”
• Pediatric dental providers, go to and select “Search for
a Provider” and “Pediatric Dental.” Pediatric dental
does not apply to plans purchased on the health
care exchange.
When you receive services from a nonparticipating provider
(a health care provider that’s not part of our network), it’s
considered out-of-network. You are responsible for your
out-of-network rate (if your plan includes out-of-network
benefits). You’re also responsible for the amount of the bill
above the out-of-network rate, as well as your copay,
deductible and/or coinsurance. If your plan doesn’t
include out-of-network benefits, any out-of-network
services you receive won’t be covered unless it’s
an emergency.
It’s important to know which doctors and hospitals are part of your
network before you choose your health plan. You can find this information
at Make sure you choose the product or network you
want to enroll in when checking to see if your doctor is in network. Not all doctors
are part of every product or network we offer.
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We offer a variety of health
plan options so you can see
the doctors you trust and
save money, too.
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CoventryOne provider network —
Select a network with doctors you trust
Provider network information
In-network care
Carelink plans
A provider network is a list of doctors, hospitals and other
providers that work with us to provide you with health care.
These providers are “participating” or “in-network.” You will
receive the highest level of covered services when seeing
an in-network provider.
Our Carelink plans are built around some of the leading
health care systems in the Carolinas. We work with
these hospitals and doctors to coordinate care, improve
the patient experience, and lower the monthly cost.
Out-of-network care
• Tier 1: enhanced benefits for using an exclusive
subset of our full network
• Tier 2: in-network benefits for the remainder of
our full network
• Tier 3: out-of-network benefits
If you choose to use an out-of-network provider you may
pay more. This is because:
• An out-of-network provider sets their own rates. These
rates are usually higher than the amount your plan “allows.”
• An out-of-network provider can bill you for anything over
the amount that Coventry allows. This is called “balance
billing.” A network provider has agreed not to do that.
• We do not base our payments on what the out-ofnetwork doctor bills you. We do not know in advance
what the doctor will charge.
Full network options
Coventry’s full network plans give you access to a variety of
local doctors and hospitals.
Carelink POS plans have three tiers of coverage:
Carelink HMO plans include coverage for Tier 1
providers only – other providers are not covered
unless it’s an emergency.
Our Carelink partners:
Carolinas HealthCare System
Duke Medicine
Emergency and travel coverage: If you have a medical
emergency, get treatment right away. Emergency services will
be covered as if you received care from an in-network
provider. You have this coverage while you’re traveling or at
home. This includes students who are away at school.
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Getting the health care benefits
you need
Getting the health care benefits you need
Prescription drug program
Prior authorization
Some medical services and prescription drugs require prior
authorization. Prior authorization means that we must approve
covered medical services in advance. This helps you and
your family receive the right care in the right place at the
right time. In-network providers usually take care of prior
authorizations for you. You are responsible for verifying that
prior authorization has been obtained.
Your plan covers prescription drugs. Your costs can vary
based on the drug and the pharmacy you use. Some
important things to remember:
Case management
If you have a serious medical condition, you may benefit from
case management. A Coventry case management nurse will
work with you and your doctor to coordinate resources that
will help you meet your health care needs.
Disease management
If you have asthma or diabetes we’ll send you information
to help you manage your condition. You may also receive
reminders if you are past due for an important test or service.
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• You should check our prescription drug list, also
called a formulary, to find out how a prescription
drug is covered.
• Your copay could be lower if you use a preferred
pharmacy. A preferred pharmacy is a retail pharmacy,
or pharmacy chain, that we work with to provide you
with lower prices. Go to and
choose “Find a Pharmacy” to find a preferred pharmacy.
• Some prescription drugs require prior authorization.
Your doctor can contact us if prior authorization
is required.
Apply beginning November 15, 2014
Steps to apply
Although you may apply for coverage up until
February 15, 2015, applying after December 15, 2014
may result in a gap in coverage.
If you have a qualifying life event after the open
enrollment period, you may be eligible for a special
open enrollment. Some of the qualifying life events
are marriage, divorce and pregnancy. See a full list
of qualifying events at
Apply for a CoventryOne plan — Applying is easy with these steps
1. Choose your plan. We have different plans to fit your budget and help meet your needs. You
can select a plan at You can work with a broker. Or, you can shop
on the Health Insurance Marketplace at Open enrollment will run from
November 15, 2014 – February 15, 2015.
2. Check to see if you qualify for help making monthly payments by applying for a plan
on the Health Insurance Marketplace website. The Marketplace will determine whether
or not you qualify for help making your monthly payments. Help is based on the size of your
family and your income. Be sure to complete all questions. You can get more information at
3. A
pply online. You can submit your application online at or at the
Health Insurance Marketplace website, if you qualify for financial help. Fill out one application for
you and any family members who will be covered by the health insurance plan. Be sure to fill in
all information. When you’re done, check over the application to make sure the information is
correct. Then print a copy for your records.
4. Make your first monthly payment. After you’re accepted and enrolled, you’ll receive
instructions for making your first monthly payment. Your enrollment will be complete after we
receive that payment.
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Eligibility and requirements
Exclusions and limitations
To qualify for a CoventryOne plan, you must be:
Certain services and supplies are not covered by your health
plan. Below is a partial list of exclusions that may apply. Please
refer to the Evidence of Coverage for a complete listing.
• A resident of the state in which you are applying and
a state in which we offer coverage
• Not be entitled to or enrolled in Medicare
We offer dependent coverage up to age 26, with some
state exceptions.
Your coverage
Your coverage stays in effect as long as you pay the
required monthly payment on time and as long as you
are eligible for the plan.* Coverage will end if you become
ineligible due to any of the following circumstances:
• Not paying your monthly bill
• Becoming a resident of a state or location in which
CoventryOne plans aren’t available
• Getting duplicate coverage and other reasons that the
law allows
Levels of coverage and enrollment
Your monthly payment may change based on the rating
factors in your state. You may pay the lowest rate available
(known as the standard premium charge). Or, you may pay
more due to age, where you live and tobacco use.
• Any service or supply that is not medically necessary
• Any service or supply that is not covered or that is directly
or indirectly a result of receiving a noncovered service
• Any service or supply for which you have no financial
liability or that was provided at no charge
• Procedures and treatments that are experimental
or investigational
• Court-ordered services or services that are a condition
of probation or parole
• Cosmetic services and surgery, and the complications
incurred as a result of those services and surgeries
• Adult dental care, appliances, dentures, implants or
X-rays, including any provider services or X-ray
examinations involving one or more teeth, the tissue or
structure around them, the alveolar process or the gums
• Immunizations for travel or employment, or unexpected
mass immunizations directed or ordered by public health
officials for general population groups
• Work-related injuries or illnesses covered by workers’
compensation laws
• Any service for which a prior authorization is required
and is not obtained
• Infertility services and supplies — any medical service,
office visit, lab, diagnostic test, prescription drug,
equipment, medicine, supply or procedure directly
or indirectly related to promoting conception by
artificial means
• Maintenance treatment or therapy that is not part of
an active treatment plan intended to or reasonably
expected to improve the member’s medical condition
or functional ability
Please call us at 1-855-449-2889 – 8 a.m. to 8 p.m. ET
(for exchange plans) or 1-866-364-5663 – 8 a.m. to 6 p.m.
ET (for off-exchange plans) if you want to confirm covered
services. Our customer service reps can also tell you how
much of the cost is covered.
*Your insurance company may automatically enroll you in the same plan, or a similar plan, for 2015. You can change your plan during Open Enrollment.
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You can always visit us
online for more information:
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Simple and affordable.
You’re covered.
Enroll today!
Toll-free: Please call us at 1-855-449-2889 – 8 a.m. to 8 p.m. ET
(for exchange plans) or 1-866-364-5663 – 8 a.m. to 6 p.m. ET
(for off-exchange plans).
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits
vary by location. Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents
for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject
to change. Providers are independent contractors and are not agents of Coventry. Provider participation may change without notice. Coventry does not
provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change. For
more information about CoventryOne refer to
Coventry does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or
health status in the administration of the plan, including enrollment and benefit determinations.
If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician
group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Health
information programs provide general health information and are not a substitute for diagnosis or treatment by physician or other health care professional.
CoventryOne health benefits and insurance products are underwritten by Coventry Health Care of the Carolinas, Inc.
80.02.351.1-NC (1/15)
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