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|In-Network Preventive Benefits|
|Coverage for Preventive Benefits under PPACA||100%||100%||100%|
|In-Network Services - PCP|
|Primary Care Physician Visits||$35 Copay||$35 Copay||$35 Copay|
|Maximum Visits per covered individual per plan year||2||4||4|
|Maximum fee plan allows per visit||$150||$150||$150|
|In-Network Services - Specialist|
|Specialist Physician Visits||NA||NA||$50|
|Maximum Visits per covered individual per plan year||NA||NA||2|
|Maximum fee plan allows per visit||NA||NA||$300|
|Tier 1 - Low Cost||
Up to 75% Discount
|$1 Copay||$1 Copay|
|Tier 2 - Generics||$10 Copay||$10 Copay|
|Tier 3 - Preferred||$40 Copay||$40 Copay|
|Tier 4 - Non-Preferred||$150 Copay||$150 Copay|
|Primary Member & Spouse||$105||$168||$209|
|Primary Member & Child(ren)||$89||$148||$199|
|SGH PLAN SUMMARY|
|When your clients choose SafeGuard Health Value they receive|
|When your clients choose SafeGuard Health Preferred they receive|
|When your clients choose SafeGuard Health Elite they receive|
|PHCS PPO NETWORK|
SGH plans include the PHCS Specific Services Network. Members have access to a premier national network that includes access to 5,000 hospitals, 107,000 ancillary facilities and approximately 917,000 practitioners. MultiPlan negotiates discounts that result in significant cost savings when members visit in-network providers, helping to maximize their health services. A PHCS logo on the SGH ID card tells both the Member and the Provider that a PHCS discount applies.
It is the Members’ responsibility to confirm the provider or facility’s continued participation in the PHCS Network and accessibility under the Specific Services program. When scheduling an appointment, Members need to specify that they have
AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, WA, WI, WV, WY
The agent/agency above is responsible for marketing and selling the product(s) you are enrolling in today. Please contact the agent if there is an issue with this purchase.
Thank you for enrolling in a SafeGuard Health plan through us! Please review and acknowledge your understanding of the below, and once completed, a copy will be provided to you for your records.
INTENDED USE VERIFICATION
By enrolling today, I agree and affirm I am enrolling for the sole purpose the plans are intended for and further affirm I was contacted because I provided my contact information for this very purpose.
I further affirm I am not enrolling for the purpose of making threats or demands for money by alleging violations of the telephone consumer protection act and/or federal trade commission do not call registry or regulations. I expressly indemnify all parties involved in enrolling in these product(s) from any alleged violations, or threats of litigation, as it relates to the telephone consumer protection act or federal trade commission do not call registry related violations.
TERMS & CONDITIONS
I acknowledge and agree that the SafeGuard Health plan is a supplement to health insurance, health plans or healthcare sharing programs. I acknowledge this is not major medical insurance and is not a substitute for major medical insurance.
I acknowledge and agree that the SafeGuard Health plan offers 100% coverage for ACA preventive services, Primary Care Physician Office Visits, Specialist Office Visits, and a prescription drug benefit (benefits vary by plan level).
I acknowledge that the SafeGuard Health plan includes access to the PHCS Specific Services PPO Network, a national network of Physicians. I acknowledge and understand that I must utilize In-Network providers; no benefits will be paid for out-of-network services.
I acknowledge and understand that the SafeGuard Health plan is subject to limitations and exclusions. It is my responsibility to thoroughly review my plan documents to ensure I understand the plan I have enrolled in and the covered benefits included in the plan
I acknowledge and agree that if there is any discrepancy between what I thought the selling Agent told me and what the actual Plan Document states, the Plan Document terms govern.
I agree that I am signing up for benefits and services that include an automatic payment plan. I expressly authorize Premier Health Solutions, LLC, as the Third-Party Administrator for the products purchased today, to automatically debit my bank account or Credit Card on the payment due date provided to collect any and all fees for my SafeGuard Health plan. I acknowledge and agree upon the effective date and the monthly payment amount. I also acknowledge and agree that my monthly payment will be automatically charged or drafted every month from the credit card, debit card or bank account I provided. Further, I attest that I am the holder of the credit card, debit card or bank account. Please Note: You will see "smemberbill.com" on your billing statement.
I may cancel automatic payments at any time by calling Customer Service at (214) 436-8885. I understand that I can also terminate the scheduled payments by providing written notification to the Customer Service team five (5) business day prior to the next scheduled payment date. This advance notice allows processing time to ensure the termination occurs prior to the next scheduled payment date. Automatic payment termination cannot be guaranteed with respect to notice provided outside of this window.
If I am not satisfied with my SafeGuard Health plan, I may cancel within thirty (30) days from my membership’s effective date and I may be eligible to receive a full refund on the monthly payment collected for that month. All cancellations must be directed to Customer Service at (214) 436-8885. Cancellations are processed Monday through Thursday from 8 a.m. to 5 p.m. and Friday from 8 a.m. to 4 p.m. Central Time. All cancellation requests must be made five (5) days prior to the billing date in order to cancel the membership for that month. This advance notice allows processing time to ensure the cancellation occurs prior to the next scheduled payment date. Cancellations cannot be guaranteed with respect to notice provided outside of this window. If a cancellation request is received on or after the recurring billing date and the payment has been drafted, the membership will terminate prior to the next billing date and the member will be covered through the next month. The billing department reserves the right to aggressively rebut and dispute any cancellation attempts made by Members via a fraud chargeback—especially if no effort has been made to resolve the issue by contacting Customer Service.
By submitting a claim during the first 30 days under the plan, I acknowledge and agree that such a submission constitutes acceptance of the plan, and their terms and submission of such a claim constitutes a waiver of any and all refund rights, including those noted in the foregoing paragraph.
By submitting a claim during the first 90 days under the plan, I acknowledge and agree that I am under a one-year contract on the plan, beginning on my active date.
I AM STRONGLY ENCOURAGED AND ADVISED TO READ ALL MEMBER MATERIALS CAREFULLY AND TO GO OVER ANY QUESTIONS OR CONCERNS WITH MY AGENT.
I acknowledge and agree that I will receive a “welcome” email within 24 hours of my enrollment, which will include my enrollment and plan information. I have the ability to download all materials, including temporary ID cards, which can then be used until the official cards are received in the mail. It is my responsibility to thoroughly review all materials. Questions can be directed to Customer Service at (214) 436-8885.
NOTICE OF VOICE CONSENT TO ELECTRONIC TRANSACTIONS, SIGNATURES AND DOCUMENTS
I consent and agree to the use of electronic signatures of documents. I consent and agree that if I participated in a recorded verification call, my voice consent shall serve as my signature. I agree I am fully responsible for reviewing this application verification and I have reviewed such application carefully to ensure my full understanding of all provisions of the coverage.
CONSENT TO ELECTRONIC TRANSACTIONS
I agree that, by using this website, my agreement or consent shall be legally binding and enforceable and the legal equivalent of my handwritten or manual signature.
By signing below, I agree to receive all documents and correspondence electronically and that I can access the internet, or the email address provide
Almost all sales are conducted telephonically and include either a recorded verification script or an e-sign authorization form, which is required with each sale. The purpose of the recorded verification call or e-sign authorization form is to ensure that you understand, among other things, what product you are purchasing, what benefits are included with that product, how much you are paying at the initial time of sale, how much you will pay monthly thereafter, and that all subsequent monthly payments will be automatically drafted from the credit or banking account you provided.
Premier Health Solutions, LLC is a Texas-based Third-Party Administrator and insurance agency. We provide comprehensive benefits administration and management services to agents, associations and carriers nationwide. We bill and collect premium and non-insured fees on behalf of numerous carriers and vendors whom we work with to help bring valuable products to the end-consumer (“Members”). Premier Health Solutions, LLC operates as a Third-Party Administrator in the state of California under the name PHSI Administrators, LLC, and as a licensed agency as PHSI Insurance Agency, LLC. We also do business under the name PremierHS, LLC in Kentucky, Ohio, Pennsylvania, South Carolina and Utah. We have a small internal agency with a handful of licensed agents; however, the product you were sold was most likely sold by a licensed agent located at third-party call center who either contracts with us directly, or with a broker with whom we do business. The contact information for the agency who marketed and sold you these products should be located at the top of this document, directly below your information. If you have any trouble contacting them, feel free to reach out to Premier Health Solutions, LLC’s Customer Service team, who will be happy to help assist with any of your needs. All of these agents work to sell various insurance and non-insurance products to Members throughout the United States.
|Standard||1-5 business days||$7.95|
|Two Day||2 business days||$15|
|Next Day||1 business day||$30|
|* Free on orders of $50 or more|