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Short Term Medical Insurance Pinnacle PlansBrought to you bySouthern Guaranty Insurance CompanyPRESTIGE PLANwww.sgicinsurance.comSTC2000AFRP
Dear Member, Thank you for choosing a MyHealth and Wellness Association (MWA) membership plan, which includes and array of savings, service and insurance benefits. Included in the MWA membership is your Short Term Medical (STM) policy. Your STM policy is insured by SGIC, a US based insurance company with its corporate headquarters in Clearwater, FL. The SGIC employees are excited to bring you personalized support to help you navigate your health insurance coverage.In the following pages, you will find a summary of your MWA membership benefits and the SGIC Short Term Medical health insurance plan. We are committed to providing members with overall product satisfaction and superior customer service. For any membership or billing related questions please don’t hesitate to contact us at 888-312-7442 Monday through Friday 9:00 a.m. to 6:00 p.m. EST. For any Benefits, Eligibility and Claims related questions, please contact us at (888) 304-7442.Sincerely,
Who is SGIC?SGIC is an independently owned and operated insurance company oering a new Short Term Medical product, the Pinnacle Plans.Our mission is to bring aordable healthcare alternatives to the average American. Our vision is to provide peace of mind through a more personal approach to the diicult to navigate medical insurance industry.The Peace of Mind People.
Enroll once for insurance coverage that last 3 terms up to 36 months.* ***Pre-existing conditions and coverage limits disclosure. This coverage is not required to comply with certain federal market requirements, principally those contained in the Aordable Care Act (ACA). Review your Certificate carefully to be sure you are aware of and understand any exclusions and limitations regarding coverage of pre-existing conditions or health benefits. Your coverage may also have lifetime and/or annual limits on health benefits. Term 112 monthsTerm 2 12 monthsTerm 312 months3 Terms Low-Cost Plans | Can be more than half the cost of other medical plans Easy Enrollment | Enroll at anytime; no qualifying event needed Flexibility | Multiple plan designs | Various policy lengths | Deductible and coinsurance options National PPO Network | No balance-billing with In-Network ProvidersWhy SGIC Pinnacle Plans
First Health NetworkThrough First Health you have access to providers, specialists, and hospitals nationwide at discounted ratesPlease visit www.sgicdualnetwork.com to verify your provider is in the network prior to receiving service. More than 5,500 hospitalsOver 980,000 professional providersOver 52,000 ancillary facilities 97% of the U.S. population has access within 20 miles to a provider in our network*In addition to the First Health Network, you have access to participating providers in the MultiPlan NetworkFirst Health is a brand name of First Health Group CorpFirst Health Limited Benefit Plan Network access is not available in New Mexico for certain fully insured limited benefit plans due to state regulations.
$8 plus Deductible and CoinsuranceCopay: Primary $4; Specialty $6Pinnacle Plans by SGIC - Plan HighlightsUrgent CarePRESTIGE$2,5 / $5, / $7, / $1, / $25,5% / 7% / 8% / %1% only if $25, deductible is selected$2,5 / $5, / $1,$,,PREMIUM$2,5 / $5, / $7, / $1, / $25, 5% / 7% / 8% / %1% only if $25, deductible is selected$5, / $1,$,,PREFERRED$5, / $7, / $1, / $25, 5% / 7% / 8% / %% only if $, deductible is selected$5, / $1,$1,,Copay: Primary $4; Specialty $6Pharmacy5$0 Urgent Care Medications $0 Maintenance Medications Free Home Delivery Up to 80% savings with Rx Discount CardBenefits are not paid for pre-existing conditions. State rules may vary. All benefits listed above may be subject to limitations and exclusions, please see your Certificate of Insurance for full details. Out-of-Network deductibles and coinsurance maximums are 200% of the in-network amounts. Out-of-Network coinsurance percentages are 30% less than in-network amounts. 1. The family deductible is capped at 3x the individual deductible. For families with more than 3 members, all covered expenses accumulate towards the family deductible, but no individual member will pay more than their individual deductible. 2. Also subject to deductible and coinsurance. 3. Includes Surgeon, Anesthesia and Facility Charges. 4. Daily limits may apply. 5. Pharmacy benefits are provided through a membership service with ReviveHealth. See ReviveHealth materials for full details.Outpatient Diagnostics Advanced Radiology $6 plus Deductible and Coinsurance $5 plus Deductible and Coinsurance$6 plus Deductible and Coinsurance Applies to Deductible and Coinsurance$60 Copay$25 copay Copay: Primary $4; Specialty $6 2Applies to Deductible and Coinsurance 3Applies to Deductible and CoinsuranceOutpatient Surgery 3Surgical Oice$6 Copay Applies to Deductible and Coinsurance 3Applies to Deductible and CoinsuranceOice Visit Applies to Deductible and Coinsurance 3Applies to Deductible and Coinsurance$6 plus Deductible and CoinsuranceWellness VisitApplies to Deductible and Coinsurance $6 Copay $4 CopayPer Person Deductible 1You pay up toCoinsurance% paid by SGICCoinsurance Maximum You pay up toCoverage Period MaximumSGIC Pays up toInpatient Services & ICU 4Applies to Deductible and Coinsurance 4Applies to Deductible and Coinsurance 4Applies to Deductible and Coinsurance 4
Pharmacy SolutionsSGIC is excited to oer a prescription membership service through our partnership with ReviveHealth that will provide access to a variety of no-cost medications, pharmacy support, and discounts.Speak with one of our licensed, registered pharmacists at your convenience to learn more about your medications and options.1, MEDICATIONS PHARMACIST CONSULTATIONRX SAVINGS CARDAccess to over 1,000 medications for both routine/maintenance needs and acute/urgent needs -- all at no extra cost!Save up to 80% on all other medications at your local pharmacy. MEDICATIONS FOR.... • High Cholesterol • Diabetes • Mental Health • Allergies • Thyroid • Asthma • Men’s Health • Women’s Health • High Blood Pressure • and more!Easy Transfers and RefillsFree Home DeliveryAll 50 StatesNo Claims or Copays
$0 at the Pharmacy for Urgent Care Prescriptions See your primary care physician or urgent care provider If prescribed one of our 70 listed medications, go to one of the 70,000 participating retail pharmacies including Walgreens and CVS. See next page for more details How Does Your Pharmacy Program Work?$0 Home Delivery on Your Maintenance Medications through ManifestRx Pharmacy • 425 Maintenance Medications • 3 Month Supply80% off not Covered PrescriptionsIf for any reason your prescription is not covered, you will have access to a discount card with up to 80% o retail costs.
Pharmacy SolutionsMedication Shipments:It takes about 3-5 business days to process, send and receive your prescription.All medications come in an unmarked box for privacy purposes.If your medication has refills left - simply transfer your medication to Revive.If your medication does not have refills left: have your provider send the new script to the pharmacy location: Manifest Rx.Transferring a Medication Refilling a Medication1. Select the ‘My Medication’ tab in your Member Portal.2. Type in the search bar the name of the medication you wish to have transferred.3. Complete the required fields.4. Select ‘Transfer My Medication’.5. You will receive an email confirmation when your order has been received.1. Select the ‘My Medication’ tab in your Member Portal --> Refill Request.2. Complete the required fields.3. You will receive an email confirmation when your order has been received.Customer CareReviveHealth1-888-220-6650 (8AM-8PM EST)Customercare@revive.health
Optional Benefit Riders Providing Additional Peace of MindRecovering from an accident or illness is stressful enough without worrying about additional bills. With our optional riders, you can focus on your recovery and your family without the added burden of financial stress. Faced with Unexpected Health Expenses?Lost Wages from Missing Work?Unpaid Bills?Have an Accident?EmergencyYou have a serious illness, or accident. Your health insurance pays your medical benefits. SituationYou are treated and recovering but now bills are adding up. SolutionCritical Illness, Accident Medical, or Accidental Death & Dismemberment Insurance from SGIC • Pays directly to you • Helps cover medical and non-medical costs • Pays in addition to your health plan • Use it as you wish
Optional Accident Medical Rider Jason selected the AME Rider with: • Benefit Amount of $10,000 • Deductible of $500He later falls and breaks his leg and has covered injuries amounting to $5,000. After paying the $500 deductible, Jason’s plan pays up to the full remainder of his covered costs.Designed to help manage the high costs of care following a covered accidental injury. Benefit Amounts Oered: $5,000 - $10,000 - $25,000 Jason enrolls in an AD&D policy with a benefit amount of $200,000. He later has a covered accident resulting in the loss of a foot. Jason files a claim within the 180 days from the covered loss and his policy pays him $100,000. Optional AD&D Rider Benefit Amounts Oered: $200,000Pay benefits for the loss of life or the loss of certain body parts or function resulting from a covered accident. *The scenarios depicted are fictional and do not represent actual cases. Please see your certificate for full details on your policy
Optional Critical Illness RiderCovered ConditionsHeart AttackStrokeKidney Failsure/ESRDCritical Heart DiagnosisMajor Organ TransplantPermanent ParalysisInvasive CancerBenefit Amounts Oered $5, - $1, - $25, The Benefit Amount will be paid for a First Diagnosis of each of the conditions listed.“1 in 2 men and 1 in 3 women will be diagnosed with cancer in their lifetime.” www.cancer.orgTwo months after purchasing her policy, Sarah is newly diagnosed with an invasive form of breast cancer, leaving her unable to work. With the Critical Illness rider, she will be able to focus on her treatment and recovery without the added stress of financial uncertainties. Sarah is paid $25, to use as she wishesUse your Payment for things like:Mortgage - Groceries - Car Payment - Child Care - Medical BillsCritical Illness Example: $25, Benefit Amount*The scenarios depicted are fictional and do not represent actual cases. Please see your certificate for full details on your policyAll conditions are paid at 1% of the benefit amount selected.
TelemedicineDentalMental HealthVisionHearingPlease don’t hesitate to contact Member Services at:1-800-992-8044 or log into your member portal at https://myhealth-and-wellness.com/ for additional details.Health Wellness LifestyleAllstate Identity ProtectionRoadside AssistanceSafeliteEmergency Travel AssistPet Insurance DiscountsFitness & NutritionVitamin DiscountsChiropractic DiscountsKarisFamily FirstLearn about all of the benefits available to you through MyHealth & Wellness AssociationMyHealth & Wellness Association (MWA) is delighted to provide our members with a dedicated platform aimed at advancing both physical and mental well-being. We achieve this by promoting a wide array of beneficial services, valuable information, and cutting-edge research through various channels dedicated to healthy living and longevity.We are fully dedicated to enhancing your experience as a member. Anticipate receiving valuable updates and resources through our digital network, and rest assured that we are continually exploring innovative ways to deliver added benefits.. Thank you for joining us on this journey to health & wellness.These benefits are applicable to your MWA Membership and are not provided under your Short Term Medical policy insured by SGIC.MWA and SGIC are separate organizations. You are purchasing both a membership in MWA and the SGIC STM Plan.
Coast to Coast | Vision This vision program oers members 10% to 60% o eyeglasses, contact lenses and other retail eyewear items as well as 10% to 30% o eye examinations and 40% to 50% o the national average on LASIK. Over 20,000 eye care professionals nationwide – including many local opticians –participate in this Benefit. Some Major Participating Eye Care Professionals Include: JCPenney, LensCrafters, Pearle Vision, Target Optical, Visionworks just to name a few. To Get Your Savings1. Select a participating provider from the enclosed list or call Customer Service for additional locations. Or go to www.findbestbenefits.com and use the Personalized Provider Directory to obtain a list of participating providers in your area2. Locate the vision network name on the front of your membership card. Give this network name to your provider when making your appointment.*3. At your appointment, simply present your membership card before getting treatment to be assured that the proper discount is applied.4. There are no limits on the number of times you may use the benefit per year.5. If you have any questions, contact Customer Service at the number listed on your membership card.6. For 40% to 50% o the overall national average for laser surgery, call 877-582-2010.Benefit GuaranteesLow Price Guarantee: If you find a lower price anywhere else on the exact same pair of prescription eyeglasses purchased at a participating location within 30 days, the dierence will be refunded.30 Day Unconditional Guarantee: Your satisfaction in the vision program and the mail order service is fully guaranteed within 30 days for an exchange or full refund. If for any reason you are not happy with a purchase at the retail locations or through the mail, return the merchandise within 30 days for an exchange or full refund.Using the Guarantees: To utilize any of the guarantees, call Customer Service at the number shown on your membership card.Members can save 15% to 50%* per visit, in most instances, on services at any of the many available dental practice locations nationwide. Dental services include: cleanings, X-rays, fillings, root canals and crowns. Members can also save on specialty care such as orthodontics and periodontics where available.Aetna | DentalThe discount program provides access to the Aetna Dental Access® network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its ailiates oers or administers the discount program. Neither ALIC nor any of its ailiates is an ailiate, agent, representative or employee of the discount program. Dental providers are independent contractors and not employees or agents of ALIC or its ailiates. ALIC does not provide dental care or treatment and is not responsible for outcomes. This benefit is not available to residents of Vermont.This is not an InsuranceProduct/Service Average Price You Pay Savings % SavedDental Cleaning $127 $68 $59 46%Dental Cleaning (Child) $93 $51 $42 45% Complete X-Rays $168 $87 $81 48% Root Canal (Anterior) $880 $536 $344 39% Complete Upper Denture $1,441 $1,003 $438 30% *Actual costs and savings may vary by provider, service and geographic location. We use the average of negotiated fees from participating providers to determine the average costs, as shown on the chart. The select regional average cost represents the average fees for the procedures listed above in Los Angeles, Orlando, Chicago and New York City, as displayed in the cost of caretool as of June 2020.
The discount program provides access to the Aetna Dental Access® network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its ailiates oers or administers the discount program. Neither ALIC nor any of its ailiates is an ailiate, agent, representative or employee of the discount program. Dental providers are independent contractors and not employees or agents of ALIC or its ailiates. ALIC does not provide dental care or treatment and is not responsible for outcomes. This benefit is not available to residents of Vermont.This is not an InsuranceReceive Up To a 20% Discount for Protecting Your Pet’s Health.Get support during pet medical emergencies and manage predictablepayments instead of surprise vet bills. SPOT is a rated-excellent provider with customizable coverage, preventative care* options, and all members can enjoy discounted premiums with SPOT. Get a 10% member discount on your first pet, plus 10% on top of that for additional pets.SPOT | Pet InsuranceEvery year, millions of people with a mental health concern struggle to find timely and eective care. Nearly half of adults and children living with mental health conditions in the United States go without any treatment at all the result of a broken system that doesn’t empower people to take that critical first step. CuraLinc improves access to mental health resources by providing around the clock telephonic support from licensed counselors who help participants improve their emotional fitness and wellbeing.This benefit is not available to residents of Vermont.This is not an InsuranceCustomized PlansCustomize the plan that is best for your pet and yourwallet. SPOT oers up to 90% reimbursement, a range of annual limits, and Accident-Only plans.Holistic Pet HealthSPOT knows that health goes beyond the conventional vet oice, and covers behavior therapy and alternative treatments. Proactive HealthSPOT has preventative carecoverage* options, which reimburse pet parents for routine care like dental cleanings, vaccinations, heartworm prevention +24/7 Pet Telehealth HelplineSPOT customers get access to a 24/7 helpline to ask veterinary experts questions about pet health, behavior, and wellness.Teladoc | Virtual Care Teladoc™ oers you the convenience of 24/7 access to U.S. board-certified physicians either a phone call or a click away. Physicians can discuss symptoms, recommend treatment options, diagnose many common non-emergency conditions and prescribe medication when medically appropriate. It’s health access at the palm of your hand. Once account registration is complete, you can request a consultation from a doctor at anytime. Consultations by phone or video are free of charge. Members can request a consultation and speaking with a representative, or by logging on to the website and clicking “Request a Consult”. During the consultation scheduling process, members will be requested to update their medical history, which can be updated online under the “My Medical History” tab or by phone when requesting your consult. Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis. 24/7 access to US licensed doctors by phone or videoOur doctors diagnose, treat, and prescribe medication Quality care, wherever you areDisclosures: Teladoc is NOT health insurance. ©Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. The state of Idaho only allows video consultations. The states of Arkansas and Delaware require the first visit to be done via video consultation, and the member may choose phone or video for subsequent visits. Prescriptions in Georgia are limited to 3 days. Teladoc can eectively treat the majority of our most common diagnoses within this three day limit.
What to Know About Short Term Medical PlansFrom our years of experience working in the health insurance industry and helping members eectively control costs, below are important details that you should be aware of with your short term medical plan. Pre-Existing Conditions One of the biggest dierences between our Plans and those available from the ACA Exchange is a Pre-Existing Condition Limitation. If you haven’t been diagnosed or treated for a medical condition in the past 12 months, or experienced symptoms that should have led you to get care but did not, this rule will not impact you. Waiting Period This plan has waiting periods which include: - Next day coverage for injuries - 5 day waiting period for sickness - 30 day waiting period for cancer Plan Benefits This plan only covers the benefits listed in your certificate. Some benefits also include visit and/or coverage period limits. Refer to your certificate for more information. The application of cost sharing is as follows: copays,deductible and coinsurance. Pre-Authorization Pre-Authorization is required for all inpatient hospitalizations, outpatient surgeries, durable medical equipment and prosthetics. Call (888) 275-7916 to get your services pre-authorized. Pre-Authorization does not guarantee coverage.
Understand What is Not CoveredKnowing exactly what your Short Term Medical Insurance does and does not cover is important. To give you the best possible experience, we oer this summary of what is not covered. Please see your Certificate for a list of exclusions, benefit amount limitations, and frequency limitations for covered services. -*Pre-existing conditions. -Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment during the waiting period, which is 5 days following the eective date. -Outpatient Prescription Drugs, Dental, and Vision services. -Contraceptive drugs and devices. -Pregnancy and related services; except for Complications of Pregnancy.-Treatment, services and supplies for a Covered Dependent who is a newborn child not yet discharged from the Hospital. -Routine foot care.-Treatment of acne or varicose veins, allergy testing and allergy injections, speech therapy, and diagnosis or treatment of a sleeping disorder. -**Diabetes, diabetic equipment, supplies and self-management training. -Genetic testing. -Hearing exams, hearing aids or fitting of hearing aids. -Treatment for cataracts. -Weight loss, non-smoking, exercise or similar programs. -Illness or injury that is self-inflicted, caused while under the influence or while engaged in a felony, in a hazardous occupation or activity, in military service, or while participating in interscholastic or intercollegiate sports. -Surgery during the first 6 months after the Eective Date of Coverage for a Covered Person for a total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma (subject to all other coverage provisions, including but not limited to the pre-existing condition exclusion); tonsillectomy, adenoidectomy, repair of deviated nasal septum or any type of surgery involving the sinus, myringotomy, tympanotomy, herniorrhaphy, or cholecystectomy. *A pre-existing condition is an illness, injury or condition for which medical advice, diagnosis, care or treatment was recommended or received from a Physician within 12 months prior to enrollment. For more details please see your certificate. **State exclusions may vary.
Frequently Asked Questions What is an In-Network Provider? An In-Network Provider is a Physician, Hospital or other healthcare Provider that is currently ailiated with the network oered by SGIC to its Policyholders.How can I locate my in-network provider for the MultiPlan Network for Limited Benefit Plans1. Call member services at (866) 870-77302. Go to www.multiplan.com/webcenter/portal/ProviderSearchand select MultiPlan Network and Limited Benefit Plan. Why should I go to an In-Network Provider? 1. In-Network Providers will provide discounts that are not available with Out-of-Network Providers.2. There is a separate Deductible and higher Coinsurance percentage which leads to more out of pocket costs for you by going to Out-of-Network Providers. 3. You can be balance-billed if you see an Out-of-Network Provider. Can I access my Short Term Medical benefits right away? Injuries are covered the day after enrollment but there is a 5 day waiting period for sickness.*Some benefits may not be covered in your plan and pre-existing conditions rules apply. What are pre-existing conditions? A pre-existing condition is an illness, injury or condition for which medical advice, diagnosis, care or treatment was recommended or received, or that had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment within the 12 months immediately preceding the Covered Person’s Coverage Eective Date. State rules may vary.What is the maximum duration length of my policy?You are selecting a Short Term Medical policy term with an auto re-apply option that will allow you to extend coverage up to 36 months. Your benefit limits, deductible, and coinsurance will reset each new term of continuous coverage. Medical conditions developed during your prior term may not be covered by additional terms. Prices may change at the start of each new policy. You may cancel at any time. Terms and conditions may vary by state. Is my policy ACA compliant?This coverage is not required to comply with certain federal market requirements, principally those contained in the Aordable Care Act (ACA). Review your Certificate carefully to be sure you are aware of and understand any exclusions and limitations regarding coverage of pre-existing conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive, care, prescription drugs, and mental health and substance use disorder services). Your coverage also has lifetime and/or annual limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.What is Pre-Authorization? Most healthcare plans require a form of pre-authorization, which is a process that protects you by verifying your procedure is medically necessary.. For this verification please call us at (888) 275-7916, as seen on your ID card. These services include all Inpatient Hospitalizations and procedures done at an Outpatient Surgical Facility but please see your certificate for full details. You can reach us at (888) 275-7916, as seen on your ID card as well. What is Coinsurance Maximum?The maximum amount of Coinsurance you will pay in a Coverage Period subject to any benefit limits specified in your certificate. The Coinsurance Maximum does not include the Deductible and Copays.