Westside HBA Direct

APEX Advantage Plan
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Schedule of Benefits 

ADVANTAGE PLAN Q & A

Q: Is this an insurance plan?
 A: No, the Advantage Plan is not an insurance product, but a self-funded plan sponsored by the 
National Consumers Benefits Association (NCBA) in which it’s members are eligible to participate

Q: Will I receive an ID Card?
A: Yes, An ID card and welcome kit will be sent to you home address.  This usually takes a few days 
after your requested effective date.

Q; What number do I can for member services?
A: For member services and question on benefits, claims, ID cards etc.: 866-826-5317

Q: I need an affordable, yet comprehensive plan for my family, one that will address my day-to- day 
health care needs, will the Advantage Plan help me?

A: Yes, it will address the bulk of your day-to-day health care by frequency.  The most common 
health care needs are for Preventive Care, Primary Care, Specialists, Urgent Care, Laboratory, 
Imaging and Prescription Drugs.  By frequency this accounts for almost 90% of health care service 
provided and the Advantage Plan provides benefits with small copayments and 100% coverage for those 
services.

Q: It covers prescriptions, can you tell me a little more?
A: The Advantage Plan provides a 6 tier prescription drug benefit with an emphasis on Generic 
Medications.  A Tier 1 , Low Cost Generic is only a $1 Copay.  Tier 2 Generics, 10% coinsurance. 
Our Pharmacy Benefit Manager, WelldyneRx has a substantial discount off of the retail level, often 
50% or more.  As an example, if a Generic medication was
$60, retail cost, WelldyneRx often has a discount of 50% or more. So the $60 Prescription could be 
reduced to $30 and your coinsurance that Generic medication would be $3.00 There are  also benefits 
for Brand and Non-Preferred Brand medications as well as limited coverage for Specialty Drugs.
 

Q: Is there an annual or monthly max on prescriptions?
A: Please see the benefit grid.  There are no monthly or annual maximum on Tiers 1 through 4.  
Tiers 5 and 6 are limited too a maximum amount per prescription

Q: Does the plan cover Preventive Care Services?
A: Yes, the plan provides 100% benefits, no, copays, no deductibles for the following Preventive 
Care services:
•   21 Preventive Care services for Adults
•   28 Preventive Care services for Women
•   31 Preventive Care services for children

Q: Is there a network of doctors or physicians:
A: Yes, the plans access one of the largest physician networks in the country Preferred Health Care 
Services (PHCS) with over 900,000 physicians nationwide.  There is no coverage for out-of-network 
services
 

Q: What if I need catastrophic coverage?
A: The HDHP/Basic MEC plan can be paired with Sedera Health – Medical Cost Sharing to provide a 
complete, comprehensive and affordable healthcare solution for you and your family.  By paring the 
HDHP/Basic MEC plan with Sedera Health, members may save up to
50% of what they could purchase a plan for on the Marketplace.
 

Product
$144.64 per Month for Member
$230.86 per Month for Member and Spouse
$214.53 per Month for Member and Children
$307.45 per Month for Member and Family

 

 

 

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