Eligibility and Benefits

Eligibility and benefits are based on our records at the time of access. This is not an authorization, nor a guarantee of eligibility, benefits, or payment.

Alessandro Kassulke — #791095845

Date of Birth: July 19, 1978 Gender: Male Address: 123 Anywhere Street, Ridgeland MS 39157

Select a policy date below to load benefit info.

Plan Details:
  • Plan Name: Premium Saver
  • Policy ID: A145B865
Carrier Info
  • Company: AmFirst Insurance Company (#AM863)
  • Customer Service: 1-800-555-5555
  • Change Healthcare Payer ID: 64090
  • SoftCare Payer ID: 01757
Claim Submissions by Mail

MWG Administrators
Claims Department
P.O. Box 16708
Jackson, MS 39236

Benefit Name Individual Family
Deductible Amount $2,000 $4,000
Coinsurance Factor 20% 20%
Coinsurance Amount $2,500 $5,000
Maximum Benefit Amount $7,000 $15,000
Professional Fee Allowable Amount N/A N/A
Professional Fee Visit Limit Per Year N/A N/A
Office Visit Allowable Amount $45 N/A
Office Visit Maximum Benefit Amount $450 $900
Office Visits Per Year 10 20
Copay Amount N/A N/A
Pediatric Dental Benefit Amount $1,000 $1,000