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Would you like a Guaranteed Issue, Nationwide PPO Health Plan that saves you money and still gives you these really great benefits?

1. Nationwide PPO coverage (this is not a local Network HMO or local Network PPO plan!)

2. $0 Health Deductibles
3. $15 to $25 for PCP Office Visit Copays

4. $25 to $50 for Specialist Office Visit Copays

5. $0 Drug Deductibles and $5 Pharmacy Copays

6. One rate for all your dependent children

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Here are some simple steps to help you choose the best Nationwide PPO Health Plan for you & your family.

1. Get your last month’s health plan bill and write that $$$ amount down.

2. Look and see how many family members are covered on your current plan.

3. Decide how many family members will go on this new plan.

4. Look at the Plan Rates below for the correct number of new plan members.

5. Call my Office so I can help you choose and sign up for the best plan at (760) 721-1689.

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It’s that simple.
Hurry!

Open Enrollment may end this month!

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Plan Rates
Plan Rates
Plan Name	MEC 1	MEC 2	MEC 3	MEC 4	MVP Bronze	MVP Silver	MVP Gold
Single	$105.47	$198.49	$295.86	$334.11	$509.58	$571.50	$621.59
You + Spouse Only	$170.33	$292.42	$435.73	$492.66	$858.66	$994.89	$1,077.85
You + Child(ren) Only	$152.94	$261.12	$389.09	$439.81	$749.87	$861.34	$925.75
Family	$205.07	$355.05	$528.98	$598.36	$1,098.97	$1,284.73	$1,382.01
Plan Options
Plan Options
Plan	MEC 1	MEC 2	MEC 3	MEC 4	MVP Bronze	MVP Silver	MVP Gold
PPO Network	PHCS / Multiplan	PHCS / Multiplan	PHCS / Multiplan	PHCS / Multiplan	PHCS / Multiplan	PHCS / Multiplan	PHCS / Multiplan
Health Deductible (Indiv / Fam)	$0 / $0	$0 / $0	$0 / $0	$0 / $0	$0 / $0	$0 / $0	$0 / $0
Max Out-of-Pocket (Indiv / Fam)	N/A	$7,350 / $14,700	$7,350 / $14,700	$7,350 / $14,700	$7,350 / $14,700	$5,000 / $10,000	$5,000 / $10,000
Preventive, Physician & Diagnostic Services
Preventive & Wellness	Included	Included	Included	Included	Included	Included	Included
(Non-Hospital Based)	Included	Included	Included	Included	Included	Included	Included
Telemedicine	$0 Copay (Unlimited)	$0 Copay (Unlimited)	$0 Copay (Unlimited)	$0 Copay (Unlimited)	$0 Copay (Unlimited)	$0 Copay (Unlimited)	$0 Copay (Unlimited)
Primary Care Doctor Office Visit	Not Covered	$25 Copay	$25 Copay	$25 Copay	$25 Copay	$15 Copay	$15 Copay
(Non-Hospital Based)	Not Covered	(2 visits per plan year)	(3 visits per plan year)	(4 visits per plan year)	(8 visits per plan year)	(10 visits per plan year)	(12 visits per plan year)
Specialist Office Visit	Not Covered	$50 Copay	$50 Copay	$50 Copay	$50 Copay	$25 Copay	$25 Copay
(Non-Hospital Based)	Not Covered	(2 visits per plan year)	(3 visits per plan year)	(4 visits per plan year)	(8 visits per plan year)	(10 visits per plan year)	(12 visits per plan year)
Urgent Care	Not Covered	$50 Copay	$50 Copay	$50 Copay	$50 Copay	$35 Copay	$35 Copay
Urgent Care	Not Covered	(2 visits per plan year)	(2 visits per plan year)	(3 visits per plan year)	(2 visits per plan year)	(3 visits per plan year)	(3 visits per plan year)
Laboratory Services & Radiology	Not Covered	$50 Copay	$50 Copay	$50 Copay	$50 Copay	$50 Copay	$50 Copay
(Non-Hospital Based)	Not Covered	(1 visit per plan year)	(2 visits per plan year)	(3 visits per plan year)	(3 visits per plan year)	(3 visits per plan year)	(4 visits per plan year)
CT / MRI / MRA / PET Scans	Not Covered	Not Covered
(Non-Hospital Based)			$350 Copay	$350 Copay	$350 Copay	$350 Copay	$350 Copay
(Prior Authorization Required)			(1 per plan year)	(2 per plan year)	(1 per plan year)	(2 per plan year)	(3 per plan year)
(Reference Based Pricing)
Allergy Services	Not Covered	Not Covered	Not Covered	Not Covered	$25 Copay	$25 Copay	$25 Copay
					(Included in PCP or Specialist	(Included in PCP or Specialist	(Included in PCP or Specialist
					Office visit limits, but	Office visit limits, but	Office visit limits, but
					separate Copay)	separate Copay)	separate Copay)
Hospital & Facility Services (Reference Based Pricing)
Inpatient Hospitalization	Not Covered	Not Covered	Not Covered	Not Covered	$350 Copay per Admission	$350 Copay per Admission	$350 Copay per Admission
(Prior Authorization Required)	Not Covered	Not Covered	Not Covered	Not Covered	(5 days per plan year)	(7 days per plan year)	(10 days per plan year)
Inpatient Visits - Physician	Not Covered	Not Covered	Not Covered	Not Covered	Included in Inpatient	Included in Inpatient	Included in Inpatient
Inpatient Visits - Physician	Not Covered	Not Covered	Not Covered	Not Covered	Hospitalization Copay	Hospitalization Copay	Hospitalization Copay
Inpatient Surgery	Not Covered	Not Covered	Not Covered	Not Covered	Included in Inpatient	Included in Inpatient	Included in Inpatient
(Prior Authorization Required)					Hospitalization Copay	Hospitalization Copay	Hospitalization Copay
(Second Opinion may be Required)					(2 surgeries per plan year)	(3 surgeries per plan year)	(4 surgeries per plan year)
Emergency Room	Not Covered	Not Covered	Not Covered	Not Covered	$350 Copay	$350 Copay	$350 Copay
Emergency Room	Not Covered	Not Covered	Not Covered	Not Covered	(1 visit per plan year)	(1 visit per plan year)	(2 visits per plan year)
Ambulance Service	Not Covered	Not Covered	Not Covered	Not Covered	$250 Copay	$250 Copay	$250 Copay
(Ground Services Only)	Not Covered	Not Covered	Not Covered	Not Covered	(1 per plan year)	(1 per plan year)	(2 per plan year)
Second Surgical Opinion (Inpatient)	Not Covered	Not Covered	Not Covered	Not Covered	$0 Copay	$0 Copay	$0 Copay
(Telephonic and Online Service)	Not Covered	Not Covered	Not Covered	Not Covered	$0 Copay	$0 Copay	$0 Copay
Outpatient Hospital or	Not Covered	Not Covered
Free Standing Facility			$350 Copay	$350 Copay	$350 Copay	$350 Copay	$350 Copay
Services and Surgery			(1 visit per plan year)	(1 visit per plan year)	(1 visit per plan year)	(2 visits per plan year)	(2 visits per plan year)
(Prior Authorization Required)
Anesthesia	Not Covered	Not Covered	Included in Outpatient	Included in Outpatient	Included in Inpatient Hospital	Included in Inpatient Hospital	Included in Inpatient Hospital
			Hospital or FSF Services	Hospital or FSF Services	or Outpatient Hospital or FSF	or Outpatient Hospital or FSF	or Outpatient Hospital or FSF
			and Surgery Copay	and Surgery Copay	Services and Surgery Copay	Services and Surgery Copay	Services and Surgery Copay
			(1 per plan year)	(1 per plan year)	(2 IP and 1 OP per plan year)	(3 IP and 2 OP per plan year)	(4 IP and 2 OP per plan year)
Second Surgical Opinion (Outpatient)	Not Covered	Not Covered	$0 Copay	$0 Copay	$0 Copay	$0 Copay	$0 Copay
(Telephonic and Online Service)	Not Covered	Not Covered	$0 Copay	$0 Copay	$0 Copay	$0 Copay	$0 Copay
Pregnancy Benefits
Professional Services	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	$350 Copay	$350 Copay
Maternity / Childbirth / Delivery	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	$350 Copay per Admission	$350 Copay per Admission
(Considered Inpatient Hospital Stay)	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	(Reference Based Pricing)	(Reference Based Pricing)
Other Services
Hospice	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
(Prior Authorization Required)	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
Home Health Care	Not Covered	Not Covered	Not Covered	Not Covered	$25 Copay	$25 Copay	$25 Copay
Home Health Care	Not Covered	Not Covered	Not Covered	Not Covered	(10 visits per plan year)	(15 visits per plan year)	(20 visits per plan year)
Treatment for Chemical Abuse	Not Covered	Not Covered	Not Covered	Not Covered
& Dependency - Inpatient					$250 Copay per Day	$250 Copay per Day	$250 Copay per Day
(Prior Authorization Required)					(5 days per plan year)	(7 days per plan year)	(10 days per plan year)
(Reference Based Pricing)
Treatment for Chemical Abuse	Not Covered	Not Covered	Not Covered	Not Covered
& Dependency - Outpatient					$25 Copay per Day	$25 Copay per Day	$25 Copay per Day
(Prior Authorization Required)					(5 days per plan year)	(7 days per plan year)	(10 days per plan year)
(Reference Based Pricing)
Pharmacy Benefits (Formulary Only)
Preventive (Generic Only)	$0 Copay	$0 Copay	$0 Copay	$0 Copay	$0 Copay	$0 Copay	$0 Copay
Non-Preventive (Retail)	$5 Copay (APS Acute List)					$5 Copay (APS Acute List)	$5 Copay (APS Acute List)
		$5 Copay (APS Acute List)	$5 Copay (APS Acute List)	$5 Copay (APS Acute List)	$5 Copay (APS Acute List)	$10 Copay (All Other Generic)	$10 Copay (All Other Generic)
		$10 Copay (All Other Generic)	$10 Copay (All Other Generic)	$10 Copay (All Other Generic)	$10 Copay (All Other Generic)	$40 Copay (Pref Brand)	$40 Copay (Pref Brand)
						$80 (Non-Pref Brand)	$80 (Non-Pref Brand)
Non-Preventive (Mail Order)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)	$15 Copay (APS Chronic List)
						$120 Copay (Pref Brand)	$120 Copay (Pref Brand)
						$240 Copay (Non-Pref Brand)	$240 Copay (Non-Pref Brand)

Walter Daniel Ortiz, Health Plan Expert

(760) 721-1689 Office

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Patriot Health Plans of America

4061 Oceanside Blvd Ste J, Oceanside, CA 92056

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