Independent Health

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Contents

1 Introduction
2 General Information
3 Summary of Benefits - IH iDirect 3 Plan
4 Personal Best Debit Card
5 Medicare Coordination and Questions
6 Important Documents & Forms

Introduction

General Information

Independent Health

www.independenthealth.com

Plan Type - iDirect 3

Group # 21650

Customer Service Telephone

(716) 631-8701 or

1-800-501-3439

Summary of Benefits - IH iDirect 3 Plan

In Network Deductible	$5,000/$10,000
In Network Out of Pocket Maximum	$5,000/$10,000
Routine Physical Exams*	$0
Primary Care Physician Copay	$0, after deductible
Specialist Copay	$0, after deductible
Laboratory Testing	$0, after deductible
Radiology Copay	$0, after deductible
Ambulance Copay	$0, after deductible
Emergency Room Copay	$0, after deductible
Urgent Care Copay	$0, after deductible
Inpatient Copay	$0, after deductible
Inpatient Maternity Copay	$0, after deductible
PT/OT/ST Copay	$0, after deductible
DME	$0, after deductible
Prosthetics & Orthotics	$0, after deductible
Prescription Copay	$0, after deductible
Out of Network Deductible	$5,000/$10,000
Out of Network Coinsurance	30%
Out of Network Out of Pocket Maximum	Unlimited

* - 1 Limited to one per year

Personal Best Debit Card

Independent Health’s personalBest!

This benefit provides another pathway to achieving a healthier lifestyle. With it, you’ll receive a $250 debit card to use toward a variety of health and wellness services. Whether you are in a single plan, or you have a spouse or dependents enrolled under your plan, a total of $250 is available to spend on a fitness club membership or after school activity programs.

For additional information please visit http://independenthealth.com/pbest .

Medicare Coordination and Questions

Do you have questions about Medicare for yourself or a family member? Feel free to call Veracity Benefits to assist:

Stephanie Nasso
Benefits Consultant/Medicare Specialist
Northwest Insurance
3960 Harlem Road
Amherst, NY 14226
(716) 256-1751
(716) 839-2529 fax

snasso@nwbcorp.com

Important Documents & Forms

		File name	Description	Size	Rev.	Time	User

Selection	File type icon	File name	Description	Size	Revision	Time	User

File type icon	File name	Description	Size	Revision	Time	User
Ċ	View Download	IH Release of Personal Health Information Form	147k	v. 2	Oct 2, 2014, 1:46 PM	Wasiewicz, Mark
Ċ	View Download	IH Benefit Summary Booklet 4 pages	308k	v. 2	Oct 2, 2014, 1:46 PM	Wasiewicz, Mark
Ċ	View Download	IH Enrollment/Change Form	103k	v. 2	Oct 2, 2014, 1:46 PM	Wasiewicz, Mark
Ċ	View Download	IH Sample Explanation of Benefits (EOB) Statement	303k	v. 2	Oct 2, 2014, 1:46 PM	Wasiewicz, Mark
Ċ	View Download	IH Benefit Summary Booklet 101 pages	2593k	v. 2	Oct 2, 2014, 1:46 PM	Wasiewicz, Mark