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Physician & Ancillary RBP Plan Structure
2024 PRODUCT information
America's Choice 500
MAXIMUM ANNUAL BENEFIT AMOUNT Annual $500,000 Lifetime $2,500,000
PER COVERED PERSON (Contracted Physician) Zero Deductible
PER COVERED PERSON (Non-Contracted Physician) Zero Deductible
PER FAMILY UNIT (Contracted Physician) Zero Deductible
PER FAMILY UNIT (Non- Contracted Physician) Zero Deductible
CONTRACTED PHYSICIAN NETWORK MAXIMUM OUT-OF-POCKET AMOUNT,
PER PLAN YEAR (Individual/Family)
Includes Deductible, Coinsurance & Copayments
Not Applicable
NON-CONTRACTED PHYSICIAN MAXIMUM OUT-OF-POCKET AMOUNT,
PER PLAN YEAR (Individual/Family)
Includes Deductible, Coinsurance & Copayments
Not Applicable
Primary Care Physician Office Visits
(Family, General Practitioner, Internist, Pediatrician, OB/GYN, Physician
Assistant, or Nurse Practitioner)
Specialist Office Visits
Physical & Occupational Therapy
Speech Therapy
Cardiac Rehabilitation
Outpatient Mental Health/Substance Abuse Office Visits
Prenatal/Postnatal Office Visits
Spinal Manipulation Chiropractic
Routine Vision Exam (One per year)
Urgent Care
TELEMEDICINE-Primary Care ZERO COPAY
TELEMEDICINE-Urgent Care ZERO COPAY
TELEMEDICINE-Mental Health Therapy ZERO COPAY
ANNUAL ADULT PHYSICAL 100% OF ALLOWABLE
ADULT IMMUNIZATIONS:
Flu Vaccine, Pneumonia Vaccine, Tetanus/Diphtheria
100% OF ALLOWABLE
MAMMOGRAM 100% OF ALLOWABLE
GYNECOLOGICAL SERVICES 100% OF ALLOWABLE
ROUTINE COLONOSCOPY 100% OF ALLOWABLE
WELL CHILD CARE/NEWBORN CARE 100% OF ALLOWABLE
ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE PLAN ALLOWABLE.
Rates effective as of June 1, 2023
COPAYMENTS
$50 per visit
10 Visits per Member per Plan Year
(Includes all visit types)
PREVENTIVE SERVICES - Click Here for a complete list.
Physician & Ancillary RBP Plan Structure
2024 PRODUCT information
America's Choice 500
Contracted Physician: Primary Care Physician Office visits (Includes all services
billed and performed by the physician except surgery, anesthesia, MRI/CT/PET/
SPECT/MRA) (Includes Family practice, General Practitioner, Internist,
Pediatrician, OB/GYN, Physician Assistant, or Nurse Practitioner)
100% AFTER COPAY,
Subject to Plan Allowable
Non-Contracted Physician: Primary Care Physician Office visits (Includes all
services billed and performed by the physician except surgery, anesthesia,
MRI/CT/PET/ SPECT/MRA) (Includes Family practice, General Practitioner,
Internist, Pediatrician, OB/GYN, Physician Assistant, or Nurse Practitioner)
Subject to Plan Allowable
Contracted Physician: Specialist office visits (Includes all services billed and
performed by the physician except surgery, anesthesia, MRI/CT/PET/
SPECT/MRA, chemotherapy, radiation, and dialysis)
100% AFTER COPAY,
Subject to Plan Allowable
Non-Contracted Physician: Specialist office visits (Includes all services billed and
performed by the physician except surgery, anesthesia, MRI/CT/PET/
SPECT/MRA, chemotherapy, radiation, and dialysis)
Subject to Plan Allowable
DIAGNOSTIC TESTING
LAB, X-RAY
$50 Copay per Visit
3 Visits per Member per Plan Year
COMPLEX DIAGNOSTIC SERVICES
CT, MRI, US, PET & Nuclear Medicine
$250 Copay per Visit
3 Visits per Member per Plan Year
SURGICAL SERVICES
Includes Facility, Surgeon Fees/Physician Fees and Anesthesia
$250 Copay per Surgery
3 Surgeries per Plan Year
EMERGENCY ROOM/OBSERVATION
Less than 24 hours
$250 Copay per Visit
2 Visit Limit for ER Accident per Plan Year.
2 Visit Limit for ER Sick per Plan Year.
EMERGENCY AMBULANCE SERVICES
Ground / Air Ambulance
100% Covered
2 Transports per Plan Year, combined
EMERGENCY
PHYSICIAN SERVICES: PERFORMED AND BILLED IN OFFICE
OUTPATIENT SERVICES WHEN PERFORMED AND BILLED IN AN OUTPATIENT FACILITY
Physician & Ancillary RBP Plan Structure
2024 PRODUCT information
America's Choice 500
ROOM AND BOARD
Includes Facility and Physician Fees
$1,000 Copay per Admission
Limit to 2 hospitalizations per plan year.
10-day limit per hospitalization.
Subject to Plan Allowable
INTENSIVE CARE UNIT
Includes Facility and Physician Fees
$1,000 Copay per Admission
Limit to 3 hospitalizations per plan year.
10-day limit per hospitalization.
Subject to Plan Allowable
SURGICAL SERVICES (ALL FEES)
Includes Facility, Surgeon Fees/Physician Fees and Anesthesia
$1,000 Copay per Surgery
Limit to 2 surgeries per Plan Year. 10-day limit
per hospitalization.
Subject to Plan Allowable
ROOM AND BOARD -
Limited to semi-private room rate.
*Dependent daughter pregnancy is not covered.
$250 Copay per Vaginal Delivery /
$500 per C-Section Delivery,
100% Coverage for other Maternity Services
INPATIENT/PARTIAL HOSPITALIZATION MENTAL HEALTHCARE SERVICES
Paid at the Facility's Semi-Private room rate
$250 per Admission
10-day limit per hospitalization,
2 stays per year
Subject to Plan Allowable
INFUSION/INJECTION DRUGS
$100 Copay per Visit
$25,000 Maximum Benefit per Plan Year
(Maximum combined with Chemotherapy benefit)
CHEMOTHERAPY/RADIATION
$100 Copay per Visit
$25,000 Maximum Benefit per Plan Year
(Maximum combined with Infusion/Injection benefit)
SUBSTANCE ABUSE REHABILITATION-INPATIENT
Paid at the facility's semi-private room rate
$250 per Admission
Subject to Plan Allowable
SUBSTANCE ABUSE REHABILITATION-OUTPATIENT
$50 Copay per Visit
10 Visit per Member
Maximum Benefit per Plan Year
INPATIENT HOSPITAL SERVICES
MATERNITY SERVICES
MENTAL HEALTH CARE SERVICES: REGULATORY REQUIREMENTS (SEE PLAN DOCUMENT)
CANCER TREATMENT SERVICES
SUBSTANCE ABUSE SERVICES: REGULATORY REQUIREMENTS (SEE PLAN DOCUMENT FOR DETAILS)
Physician & Ancillary RBP Plan Structure
2024 PRODUCT information
America's Choice 500
OTHER SERVICES
ALLERGY SHOTS
$50 Copay per Visit
100% AFTER COPAY,
Subject to Plan Allowable
HOME HEALTH CARE
$50 Copay per Visit
$500 Maximum Benefit
per plan year per Member
HOSPICE CARE
Residential / Facility
$5,000 Maximum Benefit per Plan Year
Subject to Plan Allowable
SKILLED NURSING CARE
Paid at facility's semi-private room rate
$50 Copay per Day
$5,000 Maximum Benefit per Plan Year
Subject to Plan Allowable
DURABLE MEDICAL EQUIPMENT (DME):
Limited to 12 month rental or purchase price, whichever is less
$50 Copay per Item
$500 Maximum Benefit per Plan Year
Subject to Plan Allowable
PROSTHETICS AND ORTHOTIC DEVICES
$50 Copay per Item
$2,500 Benefit Maximum per Plan Year
Subject to Plan Allowable
ALL OTHER COVERED CHARGES Subject to Plan Allowable
Rx Company America's Pharmacy Source
Phone 1-800-974-7036
Website
My Free Pharmacy Via
America's Pharmacy Source:
myfreepharmacy.com
Formulary APS Formulary
RETAIL PHARMACY COPAYMENTS
(30 DAY SUPPLY)
ZERO COPAY
MAIL ORDER OR RETAIL PHARMACY COPAYMENTS
(90 DAY SUPPLY)
ZERO COPAY
RX BENEFIT HIGHLIGHTS
RX COPAYMENTS
Physician & Ancillary RBP Plan Structure
2024 PRODUCT information
America's Choice 500
Employee $479.00
Employee + Spouse $679.00
Employee + Child(ren) $629.00
Family $929.00
Premiums
This illustration describes the plan in an easily understood manner and is presented as a matter of general information only.
The contents are not to be accepted or construed as a substitute for the provisions of the plan document or summary plan
description, which contains more exact terms and detailed provisions of the plan; and it is not to be considered a policy of
insurance.
PRECERTIFICATION
Precertification is required for all in-hospital admissions, imaging (CT/PET/MRI/MRA), home health, skilled nursing, hospice, DME
(over $500), chemotherapy/radiation, organ transplants, sleep studies, prosthetics/orthotics, therapies (chiropractic, cardiac,
PT/OT/ST), and outpatient surgery. Please refer to the plan document for a complete list of all services that require precertification
under your plan. A 50% (up to $2,500) penalty will apply for not obtaining precertification.
SPECIALTY MEDICATIONS
**SPECIALITY MEDICATIONS ARE NOT COVERED BY THE PLAN. MEDICATIONS MAY BE SEPARATELY AVAILABLE THROUGH
PHARMACY IMPORTATION PROGRAM (PIP) OR A PATIENT ASSISTANCE PROGRAM (PAP). AMERICA'S CHOICE WILL ASSIST MEMBERS
WITH THESE APPLICATIONS.
America's Choice Benefits AC 500.pdf
About Us
Why Choose Us
Our Free Benefits Include
• Telemedicine
• Health Coaching
• Diabetes Care
• Lower Your Bills
• Cashback Mall
• Student Debt Relief
• Identity Theft
• Travel Discounts
• Relationship Services
• 0% Payday Loan
• Get Paid to Exercise
• Shop Now, Pay Later
• Get Paid to Exercise
• EAP Work-Life Benefits
• EAP Counselling
• Affordable Medical Imaging
• Balanced Bill Services
• Patient Assistance Program
• Pre-Certification
• Utilization Review
• Drug Import Program
• EAP Legal Benefits
• Behavior
Modification Modules
• EAP Financial
Benefits • Network
Discounts
Personal Wellness
Financial Wellness
Health and Well-Being
IT always
SEEMS
IMPOSSIBLE
until it’s done.
America’s Choice Health Plan includes your business in
the Employer’s Business Alliance, Finally, the solution
to healthcare, whether you have only a few team
members or a large organization your company can
enjoy the benefits of big corporations.
Our approach is unique in that we align our incentives
with you to ensure we are all working toward a common
objective: to provide the highest quality healthcare at
the lowest possible price.
We offer an intuitive platform that alleviates the
burden of navigating the complexities of the
healthcare system without sacrificing quality.
Each member has their own secure online personalized
web portal called the Personal Health DashboardTM
(PHD). The PHD can be accessed from any device and
offers many resources including: Assessments, Medical
Library, Road to Wellness online behavior modification
modules, Medical Records, Health Tracker, HealtheMall
and much more.
HEALTHCARE YOUR BUSINESS DESERVES
America’s Choice 500
PRESCRIPTIONS
Retail 30 day Supply
Mail in 90 day supply
EMERGENCY ROOM
SERVICES
INPATIENT HOSPITAL
MATERNITY
Room and board limited to
semi-private room rate
PREVENTIVE SERVICES
IN-NETWORK DEDUCTIBLES
(INDIVIDUAL/FAMILY)
POLICY BENEFIT
MAXIMUM
(ANNUAL/LIFETIME)
PRIMARY CARE
OFFICE VISITS
SPECIALIST
OFFICE VISITS
URGENT CARE
THERAPY-Including: physical,
occupational, speech, cardiac
rehabilitation, and chiropractic
$50 per visit
10 Visit Max
100% Covered
Zero Deductible
$500,000/ $2,500,000
APS RX Formulary
americaspharmacysource.com
$50 copayment per visit
5 visit limit for each type of therapy.
Subject to Plan Allowable
$250 Copay
2 visit limit for ER Accident
2 visit limit for ER sick
$1,000 Copay Per Admission
Limit to 2 hospitalizations per benefit period.
10 day limit per hospitalization.
Subject to Plan Allowable
Vaginal delivery: $250 copay per admission.
C-Section delivery: $500 copay per admission.
Subject to Plan Allowable
(Includes all visit types)
Sample Snapshot
Below is just a brief summary of one of the amazing America’s Choice Health Plan benefits!
• Employee
• Employee+Spouse
• Employee+Child(ren)
• Family
$479.00
$679.00
$629.00
$929.00
Monthly Premium
Make an
Appointment Now
Corey Harper
678-749-1131
HarperHealthIns.com
UNLIMITED
$5,000
$10,000
$10,000
$20,000
$6,550/$13,100
$20,000/$40,000
2024 PRODUCT information: $5000/$10,000 HSA
Rates effective as of June 1, 2023
MAXIMUM ANNUAL BENEFIT AMOUNT
PER COVERED PERSON (Contracted Physician)
PER COVERED PERSON (Non-Contracted Physician)
PER FAMILY UNIT (Contracted Physician)
Specialist office visits 20% After Deductible
Physical & Occupational Therapy 20% After Deductible
Speech Therapy 20% After Deductible
PER FAMILY UNIT (Non-Contracted Physician)
CONTRACTED PHYSICIAN MAXIMUM OUT-OF-POCKET AMOUNT, PER PLAN YEAR (Individual/Family)
Includes Deductible, Coinsurance & Copayments
NON-CONTRACTED PHYSICIAN MAXIMUM OUT-OF-POCKET AMOUNT, PER PLAN YEAR
(Individual/Family) Includes Deductible, Coinsurance & Copayments
COPAYMENTS
Primary Care Physician Office Visits
Family and General Practitioner, and Internist
20% After Deductible
Spinal Manipulation Chiropractic 20% After Deductible
Routine Vision Exam (One per year) 20% After Deductible
Urgent Care 20% After Deductible
Cardiac Rehabilitation 20% After Deductible
Outpatient Mental Health/Substance Abuse 20% After Deductible
Prenatal/Postnatal Office Visits 20% After Deductible
TELEMEDICINE-Primary Care Included **
TELEMEDICINE-Urgent Care Included **
TELEMEDICINE-Mental Health Therapy Included **
2024 PRODUCT information: $5000/$10,000 HSA
PREVENTIVE SERVICES - Click Here for a complete list.
ANNUAL ADULT PHYSICAL 100% OF ALLOWABLE
ADULT IMMUNIZATIONS:
Flu Vaccine, Pneumonia Vaccine, Tetanus/Diphtheria
100% OF ALLOWABLE
MAMMOGRAM 100% OF ALLOWABLE
PHYSICIAN SERVICES: PERFORMED AND BILLED IN OFFICE
CONTRACTED PHYSICIAN: Primary Care Physician Office visits (Includes all
services billed and performed by the physician except surgery, anesthesia,
MRI/CT/PET/ SPECT/MRA) (Includes Family practice, General Practitioner,
Internist, Pediatrician, OB/GYN, Physician Assistant, or Nurse Practitioner)
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
NON-CONTRACTED PHYSICIAN: Primary Care Physician Office visits (Includes
all services billed and performed by the physician except surgery, anesthesia,
MRI/CT/PET/ SPECT/MRA) (Includes Family practice, General Practitioner,
Internist, Pediatrician, OB/GYN, Physician Assistant, or Nurse Practitioner)
80%, AFTER Non-Certified Providers DEDUCTIBLE,
Subject to Plan Allowable
CONTRACTED PHYSICIAN: Specialist office visits (Includes all services billed
and performed by the physician except surgery, anesthesia, MRI/CT/PET/
SPECT/MRA, chemotherapy, radiation, and dialysis)
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
GYNECOLOGICAL SERVICES 100% OF ALLOWABLE
ROUTINE COLONOSCOPY 100% OF ALLOWABLE
WELL CHILD CARE/NEWBORN CARE 100% OF ALLOWABLE
NON-CONTRACTED PHYSICIAN: Specialist office visits (Includes all services
billed and performed by the physician except surgery, anesthesia, MRI/CT/PET/
SPECT/MRA, chemotherapy, radiation, and dialysis)
80%, AFTER Non-Certified Providers DEDUCTIBLE,
Subject to Plan Allowable
2024 PRODUCT information: $5000/$10,000 HSA
SURGICAL SERVICES
Procedures & Anesthesia
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
EMERGENCY / URGENT CARE
URGENT CARE IN AN URGENT CARE FACILITY
80%, AFTER DEDUCTIBLE
Subject to Plan Allowable
EMERGENCY ROOM SERVICES
80%, AFTER DEDUCTIBLE
Subject to Plan Allowable
OUTPATIENT SERVICES WHEN PERFORMED AND BILLED IN AN OUTPATIENT FACILITY
DIAGNOSTIC TESTING
LAB, X-RAY
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
COMPLEX DIAGNOSTIC SERVICES
CT Scan, MRI, Ultra Sound, PET & Nuclear Medicine
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
MATERNITY SERVICES:
ROOM AND BOARD
Limited to semi-private room rate
Dependent daughter pregnancy is not covered
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
EMERGENCY AMBULANCE SERVICES
Ground / Air Ambulance
80%, AFTER DEDUCTIBLE
Subject to Plan Allowable
INPATIENT HOSPITAL SERVICES
ROOM AND BOARD
Paid at the facility's semi-private room rate
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
INTENSIVE CARE UNIT
Paid at the facility's semi-private room rate
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
2024 PRODUCT information: $5000/$10,000 HSA
THERAPIES
PHYSICAL & OCCUPATIONAL THERAPIES
Limited to 20 visits combined per benefit period
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
MENTAL HEALTH CARE SERVICES: SUBJECT TO GROUP SIZE AND REGULATORY REQUIREMENTS (SEE PLAN DOCUMENT)
INPATIENT/PARTIAL HOSPITALIZATION MENTAL HEALTHCARE SERVICES
Paid at the facility's semi-private room rate
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
OUTPATIENT MENTAL HEALTHCARE SERVICES
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
SUBSTANCE ABUSE SERVICES: SUBJECT TO GROUP SIZE AND REGULATORY REQUIREMENTS (SEE PLAN DOCUMENT)
SPEECH THERAPY
Limited to 20 visits per benefit period
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
CARDIAC REHABILITATION THERAPY
Limited to 36 visits per therapy, per benefit period
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
CHIROPRACTIC SERVICES/SPINAL MANIPULATION
Limited to 20 visits per benefit period
80%, AFTER DEDUCTIBLE,
Subject to Plan Allowable
SUBSTANCE ABUSE REHABILITATION-INPATIENT
Paid at the facility's semi-private room rate
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
SUBSTANCE ABUSE REHABILITATION-OUTPATIENT
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
2024 PRODUCT information: $5000/$10,000 HSA
HOSPICE CARE
Residential / Facility
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
SKILLED NURSING CARE
Paid at facility's semi-private room rate and limited to 60 days per benefit
period maximum
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
DURABLE MEDICAL EQUIPMENT (DME):
Limited to 12-month rental or purchase price, whichever is less
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
OTHER SERVICES
HOME HEALTH CARE
60 visits per benefit period
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
Phone 855-633-2579
Website MedalistRx.com
Formulary Medalist Formulary
PROSTHETICS AND ORTHOTIC DEVICES:
Max amount of $6,500 per member/per plan year
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
ALL OTHER COVERED CHARGES
80% AFTER DEDUCTIBLE,
Subject to Plan Allowable
RX BENEFIT HIGHLIGHTS
Rx Company Medalist Rx
2024 PRODUCT information: $5000/$10,000 HSA
SPECIALTY MEDS
18-29 Years 30-44 Years 45-54 Years 55-64 Years
Employee $528.57 $543.71 $562.61 $601.40
Employee + Spouse $917.13 $947.42 $985.20 $1,062.79
Employee + Child(ren) $841.42 $868.68 $902.68 $972.51
Family $1,310.71 $1,356.13 $1,412.81 $1,529.19
ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE PLAN ALLOWABLE.
Premiums by Age Band
**SPECIALITY MEDICATIONS ARE NOT COVERED BY THE PLAN. MEDICATIONS MAY BE SEPARATELY AVAILABLE
THROUGH PHARMACY IMPORTATION PROGRAM (PIP) OR A PATIENT ASSISTANCE PROGRAM (PAP). AMERICA'S
CHOICE WILL ASSIST MEMBERS WITH THESE APPLICATIONS.
PRECERTIFICATION
Precertification is required for all in-hospital admissions, imaging (CT/PET/MRI/MRA), home health, skilled nursing, hospice, DME (over $500),
chemotherapy/radiation, organ transplants, sleep studies, prosthetics/orthotics, therapies (chiropractic, cardiac, PT/OT/ST), and outpatient
surgery. Please refer to the plan document for a complete list of all services that require precertification under your plan. A 50% (up to $2,500)
penalty will apply for not obtaining precertification.
This illustration describes the plan in an easily understood manner and is presented as a matter of general information only.
The contents are not to be accepted or construed as a substitute for the provisions of the plan document or summary plan description, which contains more exact
terms and detailed provisions of the plan; and it is not to be considered a policy of insurance.
** Telemedicine Disclaimer - Inclusion of this benefit is subject to change according to the Consolidated Appropriations Act, 2023
RX COPAYMENTS
RETAIL PHARMACY COPAYMENTS
(30 DAY SUPPLY)
GENERIC-$10 COPAYMENT AFTER DEDUCTIBLE
BRAND NAME FORMULARY -$45 COPAYMENT AFTER
DEDUCTIBLE
NON-PREFERRED BRAND - $85 COPAYMENT AFTER DEDUCTIBLE
MAIL ORDER OR RETAIL PHARMACY COPAYMENTS
(90 DAY SUPPLY)
GENERIC-$30 COPAYMENT AFTER DEDUCTIBLE
BRAND NAME -$90 COPAYMENT AFTER DEDUCTIBLE
NON-PREFERRED BRAND - $150 COPAYMENT AFTER
DEDUCTIBLE
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