FECHA DE EFECTIVIDAD: enero 1, 2023 hasta 31 diciembre 2023
Individual
Pareja
Familiar
$591.00
$396.00
$210.00
$495.00
$175.00
$352.00
DISEÑO DEL PLAN
COBERTURA MÉDICA
MOOP
Hospital
Ambulatory Surgery
Office visits
Chiropractor
Physical Therapy
Respiratory Therapy
Emergency Room - Accident
Emergency Room - Sickness
Urgency Center
Diag. Lab - Special Network
X - Rays
Diag. & Office Surgical Procedures
Specialized Test
Endoscopy Services
Medical Component Drug List
Radiotherapy
Chemotherapy
US Services
Trasplante de Organos
Vision
NO APLICA
$100.00
$50.00
$5/$15/$15
$15 visit
$7 max. 15 therapies
$7 max. 10 therapies
$0.00
$75.00
$15.00
30% IN / 45% ON
$30
$30
$30
$30
50% coinsurance up to a maximum benefit of $25k per policy year
20%
20%
ER & Serv. not available in PR 20%
$250k lifetime max.
Max. benefit of $125.00 per policy year
Salud MAX
NO APLICA
$100.00
$50.00
$5/$15/$20
$15 visit
$7 max. 15 therapies
$7 max. 10 therapies
$0.00
$75.00
$15.00
35% IN / 50% ON
$35
$35
$35
$35
No cubierto
20%
20%
ER & Serv. not available in PR 20%
$250k lifetime max.
Max. benefit of $125.00 per policy year
Salud 1
COBERTURA DE FARMACIA
Drug Coverage
Dispensing Rule
MAB - First Level (Generic & Brand)
MAB - Secound Level (Generic & Brand)
Maximum Allowed Benefit
Oral Chemotherapy
O TC
Retail
Generic Preferred
Generic Non Preferred
Brand Preferred
Brand Non Preferred
Specialty Drugs
Mail Order / 90 Days
Generic Preferred
Generic Non Preferred
Brand Preferred
Brand Non Preferred
PDL B with Step Therapy & Special Network
Penalty Plus Brand Copay
$5,000.00
80%
Applies to Point of Service
20%
$1.00
$5.00
$5.00
25% Min $25
35% Min $40
50% coinsurance up to maximum benefit of $25k per policy year
$10.00
$10.00
25% Min $50
5% Min $80
Generic/Brand
Value Formulary with Step Therapy & Special Network
No aplica
$1,000.00
80%
Applies to Point of Service
20%
$1.00
$5.00
$5.00
No cubierto
No cubierto
No cubierto
$10.00
$10.00
No cubierto
No cubierto
Generic Only
COBERTURA DENTAL
Max. PMPY
Diagnostic & Preventive
Space Maintainers
Restorative
Oral Surgery
Endodontic
Periodontic
Prosthesis
Orthodontics
$1,000.00
0%
30%
30%
30%
30%
30%
50%
No cubierto
DAI
$1,000.00
0%
30%
30%
30%
30%
30%
50%
No cubierto
DB8
* The proposal is subject to meeting eligibility rules for employer sponsored plans only.
** This proposal considers a single carrier arrangement.
Solicita tu plan:
Centro de servicio:
787.302.0210 • admin@finanzas360pr.com
*Se requerirá planilla trimestral del Fondo del Seguro del Estado o Departamento de Trabajo. Este documento representa un resumen de los beneficios básicos que ofrecemos a los grupos y varían de acuerdo con el producti o servicio seleccionado. Su contenido está sujeto a las disposiciones de la póliza, refiérase a la misma para ver los detalles de la cubierta. Ciertas restricciones, términos y condiciones pueden aplicar. Suscrito por MCS Life Insurance Company.
