Plan Information

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The benefits shown below reflect the amount you pay when you see a participating provider (or an in-network provider).

Basic Plan Details
Plan Overview
Estimated Monthly Premium
The amount you pay for your health insurance every month. You can pay your premium yourself, or through an employer if they offer insurance. (In addition to your premium, you usually have to pay other costs for your healthcare, including a deductible, copayments, and/or coinsurance.)
Plan Level(Metal Tier)
HSA Qualified
Certificate Of Coverage (COC)
A formal document that explains the health benefits you and your dependents have under your health insurance plan, and what is not covered by your plan.
Summary of Benefits and Coverage (SBC)
A short, plain-language summary of your health plan.
Formulary Link
A list of prescription drugs covered by your insurance plan or a separate prescription drug plan. It may also be called a drug list.
Quality Rating
Customer Satisfaction Rating
Cost Sharing Overview
Deductibles
The amount of money you pay for covered healthcare services before your insurance company starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and your insurance company pays the rest
Prescription Drug Deductible
This is the amount you must pay each year for your prescriptions before your healthcare plan begins to pay its share of your covered drugs.
Out-of-Pocket Maximum
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
Prescription Drug Out-of-Pocket Maximum
The most you have to pay for prescription drugs in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of your additional prescription drugs.
Network Information
Plan Type
Network Description
Out-of-Network(OON) Coverage
Payments for healthcare providers who are not contracted with your insurance company for reimbursement. In many insurance plans, going out of your network to choose a provider will cost you most.
Primary Care Provider(PCP) Required
A primary care provider is a doctor or other healthcare provider who directly provides or coordinates a range of healthcare services for a patient. Some insurance plans require you to have a primary care provider in order to participate in the plan.
Do I need a referral to see a Specialist?
Search for a Provider
Physician Services
Preventive Care
Primary Care Visit
Patient Centered Medical Home (PCMH)
Specialist Visit
A visit with a doctor who is not your primary care doctor. These doctors focus on a specific types of health care. Examples of specialists include obstetricians, surgeons, or cardiologists.
Prescription Drugs - 30 Day Supply from a Retail Pharmacy
Urgent and Emergency Care
Hospital Services
Outpatient Services
Mental Health, Substance Abuse & Behavioral Health
Outpatient Rehabilitation Services
Additional Information
This is a partial summary of benefits and coverage and should not be considered a contract. This information, including all quoted rates, should be used for informational purposes only. Changes may be made to the benefits and coverage policies described here. You should only rely upon the Evidence of Coverage document provided to you from your health insurance company for information on rates, covered benefits, limitations and exclusions.

*This plan does not cover abortion except in very limited circumstances (check your policy or plan document for further information). No portion of the premium paid for this plan is placed in an allocation account, established for the coverage of elective abortion services, and defined by 45 CFR section 156.280(e)(3).

Insurance companies provide updates to their provider networks to HealthSource RI on a monthly basis. This may impact the accuracy of the information above. Please call or consult the website of your chosen insurance provider for the most up-to-date information regarding in and out-of-network providers.
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