We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs.
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- Elwin Rodgers
- 8 years ago
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2 We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs. Optima Health Products and Services Our Value Statement 1
3 TABLE OF CONTENTS 2
4 CONSUMER-DIRECTED HEALTH PLANS VANTAGE PRODUCTS optimahealth.com 3
5 Comparison of Benefits OPTIMA EQUITY VANTAGE PLANS optimahealth.com 4
6 Optima Equity Vantage Services *2500/100% 2500/90% 2500/80% *3000/100% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit 5
7 Optima Equity Vantage 2 2 Services 3000/90% 3000/80% 4000/100% 4000/80% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit 6
8 Optima Equity Vantage Services 5000/100% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. 2 2 Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit 7
9 Comparison of Benefits OPTIMA EQUITY POSA PLANS optimahealth.com 8
10 Optima Equity POSA 2 Services *2500/100% 2500/90% 2500/80% *3000/100% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 9
11 Optima Equity POSA 2 2 Services 3000/90% 3000/80% 4000/100% 4000/80% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 10
12 Optima Equity POSA 2 2 Services 5000/100% In-Network Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 11
13 Comparison of Benefits OPTIMA DESIGN VANTAGE PLANS optimahealth.com 12
14 Optima Design Vantage Services 1500/100% 1500/90% 1500/80% 2500/100% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit( *Specialty Drugs Out-of-Pocket Limit 13
15 Optima Design Vantage Services 2500/90% 2500/80% 3000/100% 3000/90% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit ( *Specialty Drugs Out-of-Pocket Limit 14
16 Optima Design Vantage Services 3000/80% 4000/100% 4000/80% 5000/100% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit( *Specialty Drugs Out-of-Pocket Limit 15
17 Comparison of Benefits OPTIMA DESIGN RX DEDUCTIBLE VANTAGE PLANS optimahealth.com Underwritten by Optima Health Plan 16
18 Optima Design Vantage RxDed Services 3000/90% 3000/80% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit( *Specialty Drugs Out-of-Pocket Limit 17
19 Optima Design Vantage RxDed Services 4000/100% 4000/80% 5000/100% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit( *Specialty Drugs Out-of-Pocket Limit 18
20 Comparison of Benefits OPTIMA DESIGN POSA PLANS optimahealth.com 19
21 Optima Design POSA Services 1500/100% 1500/90% 1500/80% 2500/100% Annual Deductible $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $2,500/$5,000 Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Physician Office Visit 100% AD 90% AD 80% AD 100% AD Preventive Care Visits Covered at 100% Covered at 100% Covered at 100% Covered at 100% Injectable and Infused Medications 100% AD 90% AD 80% AD 100% AD Preventive Screenings (Mammograms and Colonoscopies) Covered at 100% Covered at 100% Covered at 100% Covered at 100% Maternity Care 100% AD 90% AD 80% AD 100% AD Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Outpatient Surgery 100% AD 90% AD 80% AD 100% AD Outpatient Therapy Services 100% AD 90% AD 80% AD 100% AD Outpatient Rehabilitation Services 100% AD 90% AD 80% AD 100% AD Outpatient Diagnostic Procedures (Diagnostic Procedures, X-ray, Ultrasound, and 100% AD 90% AD 80% AD 100% AD Doppler Studies) Outpatient Advanced Imaging/Testing (Sleep Studies, MRI, MRA, CT, CTA, and PET Scans) 100% AD 90% AD 80% AD 100% AD Outpatient Treatments (Chemo, Radiation, IV, and Inhalation Therapy Services) 100% AD 90% AD 80% AD 100% AD Inpatient Hospital Services Inpatient Care 100% AD 90% AD 80% AD 100% AD Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Emergency Department 100% AD 90% AD 80% AD 100% AD Urgent Care Center 100% AD 90% AD 80% AD 100% AD Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testing require pre-authorization. Inpatient Services 100% AD 90% AD 80% AD 100% AD Outpatient Visits 100% AD 90% AD 80% AD 100% AD Employee Assistance Program Other Services 3 visits per presenting issue Diabetic Supplies and Infusion Sets 100% AD 90% AD 80% AD 100% AD Diabetes Education and Insulin Pumps Covered at 100% Covered at 100% Covered at 100% Covered at 100% Prescription Drug Benefit (mail order $10/$30/$50/$100 available for most drugs) *Specialty Drugs 1 Copayment or Coinsurance per 31- day supply 1 Copayment or Coinsurance per 31- day supply 1 Copayment or Coinsurance per 31- day supply 1 Copayment or Coinsurance per 31- day supply In-Network Out-of-Pocket Limit $1,500/$3,000 $3,000/$6,000 $4,000/$8,000 $2,500/$5,000 Out-of-Network Deductible $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,500/$7,000 Out-of-Network Coinsurance 70% AD 70% AD 70% AD 70% AD Out-of-Network Out-of-Pocket Limit $7,500/$15,000 $7,500/$15,000 $7,500/$15,000 $7,500/$15,000 AD After Deductible * Specialty Drugs are available only through the mail-order specialty drug provider. 20 DesignPOSA.COB_0713
22 Optima Design POSA Services 2500/90% 2500/80% 3000/100% 3000/90% Annual Deductible $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Physician Office Visit 90% AD 80% AD 100% AD 90% AD Preventive Care Visits Covered at 100% Covered at 100% Covered at 100% Covered at 100% Injectable and Infused Medications 90% AD 80% AD 100% AD 90% AD Preventive Screenings (Mammograms and Colonoscopies) Covered at 100% Covered at 100% Covered at 100% Covered at 100% Maternity Care 90% AD 80% AD 100% AD 90% AD Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Outpatient Surgery 90% AD 80% AD 100% AD 90% AD Outpatient Therapy Services 90% AD 80% AD 100% AD 90% AD Outpatient Rehabilitation Services 90% AD 80% AD 100% AD 90% AD Outpatient Diagnostic Procedures (Diagnostic Procedures, X-ray, Ultrasound, and 90% AD 80% AD 100% AD 90% AD Doppler Studies) Outpatient Advanced Imaging/Testing (Sleep Studies, MRI, MRA, CT, CTA, and PET Scans) 90% AD 80% AD 100% AD 90% AD Outpatient Treatments (Chemo, Radiation, IV, and Inhalation Therapy Services) 90% AD 80% AD 100% AD 90% AD Inpatient Hospital Services Inpatient Care 90% AD 80% AD 100% AD 90% AD Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Emergency Department 90% AD 80% AD 100% AD 90% AD Urgent Care Center 90% AD 80% AD 100% AD 90% AD Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testing require pre-authorization. Inpatient Services 90% AD 80% AD 100% AD 90% AD Outpatient Visits 90% AD 80% AD 100% AD 90% AD Employee Assistance Program Other Services 3 visits per presenting issue Diabetic Supplies and Infusion Sets 90% AD 80% AD 100% AD 90% AD Diabetes Education and Insulin Pumps Covered at 100% Covered at 100% Covered at 100% Covered at 100% Prescription Drug Benefit (mail order available for most drugs) *Specialty Drugs 1 Copayment or Coinsurance per 31- day supply $10/$30/$50/$100 1 Copayment or Coinsurance per 31- day supply 1 Copayment or Coinsurance per 31-day supply 1 Copayment or Coinsurance per 31-day supply In-Network Out-of-Pocket Limit $4,000/$8,000 $4,500/$9,000 $3,000/$6,000 $4,500/$9,000 Out-of-Network Deductible $3,500/$7,000 $4,000/$8,000 $4,000/$8,000 $4,000/$8,000 Out-of-Network Coinsurance 70% AD 70% AD 70% AD 70% AD Out-of-Network Out-of-Pocket Limit $7,500/$15,000 $8,000/$16,000 $8,000/$16,000 $8,000/$16,000 AD After Deductible * Specialty Drugs are available only through the specialty drug provider. 21 DesignPOSA.COB_0713
23 Optima Design POSA Services 3000/80% 4000/100% 4000/80% 5000/100% Annual Deductible $3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $5,000/$10,000 Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Physician Office Visit 80% AD 100% AD 80% AD 100% AD Preventive Care Visits Covered at 100% Covered at 100% Covered at 100% Covered at 100% Injectable and Infused Medications 80% AD 100% AD 80% AD 100% AD Preventive Screenings (Mammograms and Colonoscopies) Covered at 100% Covered at 100% Covered at 100% Covered at 100% Maternity Care 80% AD 100% AD 80% AD 100% AD Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Outpatient Surgery 80% AD 100% AD 80% AD 100% AD Outpatient Therapy Services 80% AD 100% AD 80% AD 100% AD Outpatient Rehabilitation Services 80% AD 100% AD 80% AD 100% AD Outpatient Diagnostic Procedures (Diagnostic Procedures, X-ray, Ultrasound, and Doppler 80% AD 100% AD 80% AD 100% AD Studies) Outpatient Advanced Imaging/Testing (Sleep Studies, MRI, MRA, CT, CTA, and PET Scans) 80% AD 100% AD 80% AD 100% AD Outpatient Treatments (Chemo, Radiation, IV, and Inhalation Therapy Services) 80% AD 100% AD 80% AD 100% AD Inpatient Hospital Services Inpatient Care 80% AD 100% AD 80% AD 100% AD Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Emergency Department 80% AD 100% AD 80% AD 100% AD Urgent Care Center 80% AD 100% AD 80% AD 100% AD Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testing require pre-authorization. Inpatient Services 80% AD 100% AD 80% AD 100% AD Outpatient Visits 80% AD 100% AD 80% AD 100% AD Employee Assistance Program Other Services 3 visits per presenting issue Diabetic Supplies and Infusion Sets 80% AD 100% AD 80% AD 100% AD Diabetes Education and Insulin Pumps Covered at 100% Covered at 100% Prescription Drug Benefit (mail order available for most drugs) *Specialty Drugs 1 Copayment or Coinsurance per 31- day supply 1 Copayment or Coinsurance per 31-day supply $10/$30/$50/$100 Covered at 100% 1 Copayment or Coinsurance per 31-day supply DesignPOSA.COB_0713 Covered at 100% 1 Copayment or Coinsurance per 31-day supply In-Network Out-of-Pocket Limit $5,000/$10,000 $4,000/$8,000 $6,000/$12,000 $5,000/$10,000 Out-of-Network Deductible $4,500/$9,000 $5,000/$10,000 $5,500/$10,500 $6,000/$12,000 Out-of-Network Coinsurance 70% AD 70% AD 70% AD 70% AD Out-of-Network Out-of-Pocket Limit $9,000/$18,000 $9,000/$18,000 $10,000/$20,000 $10,000/$20,000 AD After Deductible * Specialty Drugs are available only through the mail-order specialty drug provider. 22
24 Comparison of Benefits OPTIMA DESIGN POSA RX DEDUCTIBLE PLANS optimahealth.com Underwritten by Optima Health Plan 23
25 Optima Design POSA RxDed Services 3000/90% 3000/80% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit ( *Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Deductible Out-of-Network Coinsurance Out-of-Network Out-of-Pocket Limit 24
26 Optima Design POSA RxDed Services 4000/100% 4000/80% 5000/100% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Benefit( *Specialty Drugs Out-of-Network Out-of-Pocket Limit In-Network Out-of-Pocket Limit Out-of-Network Deductible Out-of-Network Coinsurance 25
27 OPTIMA VANTAGE PRODUCTS optimahealth.com 26
28 Comparison of Benefits OPTIMA VANTAGE PLANS optimahealth.com 27
29 Optima Vantage Services 10/20 (SG)** 10/25 15/35 20/40 Annual Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( ***Specialty Drugs Out-of-Pocket Limit 28
30 Optima Vantage Services 25/50 15/80% 20/80% 25/70% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. ( Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs Out-of-Pocket Limit 29
31 Optima Vantage Services 500/15/80% 500/20/80% 1000/20/80% 1500/20/80% Annual Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs Out-of-Pocket Limit 30
32 2 2 Optima Vantage Services 1000/25/70% 2000/25/70% Annual Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs Out-of-Pocket Limit 31
33 Comparison of Benefits OPTIMA VANTAGE ASSOCIATION PLANS optimahealth.com 32
34 Optima Vantage Association Services 10/20 10/25 15/35 20/40 Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs Out-of-Pocket Limit 33
35 Optima Vantage Association Services 25/50 15/80% 20/80% 25/70% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs Out-of-Pocket Limit 34
36 Optima Vantage Association Services 500/15/80% 500/20/80% 1000/20/80% 1500/20/80% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs Out-of-Pocket Limit 35
37 2 2 Optima Vantage Association Services 1000/25/70% 2000/25/70% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs Out-of-Pocket Limit 36
38 Comparison of Benefits OPTIMA POSA PLANS optimahealth.com 37
39 Optima POSA Services 10/20 (SG)** 10/25 15/35 20/40 Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. ( Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse ServicesIncludes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of- Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 38
40 Optima POSA Services 25/50 15/80% 20/80% 25/70% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 39
41 Optima POSA Services 500/15/80% 500/20/80% 1000/20/80% 1500/20/80% In-Network Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 40
42 2 2 Optima POSA Services 1000/25/70% 2000/25/70% In-Network Annual Deductible Physician Office Services Copayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient ServicesCopayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 41
43 Comparison of Benefits OPTIMA POSA ASSOCIATION PLANS optimahealth.com 42
44 Optima POSA Association Services 10/20 10/25 15/35 20/40 Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of- Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 43
45 Optima POSA Association Services 25/50 15/80% 20/80% 25/70% Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental illnesses. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 44
46 Optima POSA Association Services 500/15/80% 500/20/80% 1000/20/80% 1500/20/80% In-Network Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 45
47 2 2 Optima POSA Association Services 1000/25/70% 2000/25/70% In-Network Annual Deductible Physician Office ServicesCopayment or Coinsurance applies to covered services performed in the physician s office. Additional Copayment or Coinsurance may apply to outpatient therapy, rehabilitative services, and outpatient advanced imaging procedures done in the physician s office. Outpatient Services Copayment or Coinsurance applies to covered services provided in a free-standing outpatient facility, hospital outpatient facility, in a physician s office, or in the member s home as part of Skilled Home Health Care Services benefit. Inpatient Hospital Services Emergency Services Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Behavioral Healthcare and Substance Abuse Services Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Employee Assistance Program Other Services Prescription Drug Default Benefit ( **Specialty Drugs In-Network Out-of-Pocket Limit Out-of-Network Coinsurance Out-of-Network Deductible Out-of-Network Out-of-Pocket Limit 46
48 Comparison of Benefits ESSENTIAL AND STANDARD PLANS optimahealth.com 47
49 Pre-Authorization is required for in-office surgery. Includes covered services performed in the physician's office during the physician office visit. Includes, but not limited to office consult, in-office surgery, lab, X-ray, injections, diagnostic, and treatment services. Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Members up to age 18 are covered for one examination including one pair of lenses and frames every 12 months performed by a participating EyeMed provider. Limited to generic drugs unless a generic drug is not available. 48
50 Pre-Authorization is required for in-office surgery. Includes covered services performed in the physician's office during the physician office visit. Includes, but not limited to office consult, in-office surgery, lab, X-ray, injections, diagnostic, and treatment services. Includes those emergency department facility, physician, and ancillary services that are rendered during an emergency visit. Includes inpatient and outpatient services for the treatment of mental health and substance abuse, and biologically based mental health. Inpatient mental healthcare and outpatient psychological testingrequire pre-authorization. Members up to age 18 are covered for one examination including one pair of lenses and frames every 12 months performed by a participating EyeMed provider. Limited to generic drugs unless a generic drug is not available. 49
51 EXCLUSIONS AND LIMITATIONS VANTAGE PRODUCTS optimahealth.com 50
52 PHARMACY PRESCRIPTION DRUG RIDER EXCLUSIONS VANTAGE PRODUCTS optimahealth.com 51
53 EXCLUSIONS AND LIMITATIONS AND OTHER COVERAGE TERMS Underwritten by Optima Health Plan 52
54 Underwritten by Optima Health Plan 53
55 EXCLUSIONS AND LIMITATIONS VANTAGE PRODUCTS The following is a list of Exclusions and Limitations that generally apply to all Optima Health plans. Once you are an enrolled member please refer to your Plan documents for the Exclusions and Limitations specific to your plan. Underwritten by Optima Health Plan v
56 EXCLUSIONS AND LIMITATIONS- VANTAGE PRODUCTS Services mean both medical and behavioral health (mental health) services and supplies unless We specifically tell You otherwise. We do not cover any services that are not listed in the Covered Services section of the Optima coverage documents for your plan. We do not cover any services that are not Medically Necessary. We sometimes give examples of specific services that are not covered but that does not mean that other similar services are covered. Some services are covered only if We authorize them. When We say You or Your We mean You and any of Your family members covered under the Plan. A Abortion is covered in the first 12 weeks of pregnancy. After 12 weeks abortion is covered if the mother s life is at risk, if there are major fetal abnormalities, or in the case of rape or incest. Acupuncture is not covered. Adaptations to Your Home, Vehicle, or Office are not covered. Handrails, ramps, escalators, elevators, or any other changes because of a medical condition or disability are not covered. Against Medical Advice (AMA). If You decide not to follow a prescribed treatment for a medical condition the Plan will not assume any further liability for that condition unless You later decide to follow prescribed treatment under the care of the ordering physician. Coverage is subject to the terms of Your Plan. Ambulance Service for non-emergency transportation is not covered unless We authorize the service. Non medical Ancillary Services You are referred to are not covered. Vocational rehabilitation services, employment counseling, relationship counseling for unmarried couples, pastoral counseling, expressive therapies, health education, or other non-medical services are not covered. General Anesthesia in a Physician s office is not covered. Aromatherapy is not covered. Artificial Hearts or mechanical heart devices, or their placement is not covered. Autopsies are not covered. B Batteries are not covered except for motorized wheelchairs and cochlear implants when authorized. Biofeedback is not covered unless We authorize it. Blood and Blood Products are not covered. We do not cover any costs for finding blood donors. We do not cover the cost of transportation and storage of blood in or outside the Plan s Service Area. Bone Densitometry Studies more than once every two years are not covered unless We authorize them. 55
PLAN DESIGN AND BENEFITS POS Open Access Plan 1944
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SERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE
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We know that you value your employees. Thank you for considering Optima Health to meet your employees healthcare needs.
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2015 Medical Plan Summary
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC.
HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible
Consumers Mutual Insurance of Michigan: Choice Medium Deductible Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.consumersmutual.org or by calling 1-877-371-9112. Important
Highmark Delaware: Shared Cost Blue EPO 3000 Coverage Period: 01/01/2016-12/31/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbsde.com or by calling 1-888-601-2242. Important
What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket
Regence BlueShield: Regence Direct Gold with Dental, Vision, Individual Assistance Program Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
BlueSelect Silver ValueTwo for Individuals
BlueSelect Silver ValueTwo for Individuals Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single Plan Type: PPO This is only
Companion Life Insurance Company: Middlebury College Student Health Insurance Plan Coverage Period: 08/15/2015-08/14/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to
Important Questions Answers Why this Matters:
Bronze 60 EPO - Network Name: EPO Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO
LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-870-3057. Important Questions
Member s responsibility (deductibles, copays, coinsurance and dollar maximums)
MICHIGAN CATHOLIC CONFERENCE January 2015 Benefit Summary This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at PacificSource.com or by calling 1-888-977-9299 Important
Greater Tompkins County Municipal Health Insurance Consortium
WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not
Highlights of your Health Care Coverage
MEDICAL COST SHARE OPTIONS Individual Deductible PCY (Family deductible 2X Individual) Coinsurance (Member's percentage of costs after deductible based on allowable charges) Individual Out of Pocket Maximum
Important Questions Answers Why this Matters: In-network: $2,000 Single / $4,000 Family Out-of-network: $3,000 Single / $6,000 Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.independenthealth.com or by calling 1-800-501-3439. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
How Much Does My In-Network Provider Cover?
OMB Control Numbers 1545-2229, Affinity Health Plan: Affinity Essential Silver Plan Coverage Period: 01/01/2014 12/31/2014 This is only a summary. If you want more detail about your coverage and costs,
$500 Individual / $1,500 Family Does not apply to preventive care and pharmacy
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mhhealthplan.org or by calling 1-713-338-6535 or 1-888-642-5040.
Group Health Options, Inc.: Puget Sound Energy, Inc. Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Group Health Options, Inc.: Puget Sound Energy, Inc. Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/2015 to 1/1/2016 Coverage for: Group Plan Type: POS This
Coventry Health Care of Missouri
Small Group PPO Schedule of Benefits: Coventry Health Care of Missouri Plan ID#: Platinum Carelink from Coventry A000-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain
Benefit Highlights for UNC Greensboro students
bcbsnc.com/uncg Benefit Highlights for UNC Greensboro students Effective 08/01/2016 StdGrp, 4/16 U9096a, 5/16 Table of Contents This brochure is a general summary of the insurance plan offered by Blue
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthchoiceessential.com/members/member_benefits.aspx
HNE Premier 1 (HMO) and HNE Premier 2 (HMO)
2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I
Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO
Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary
$ No. Important Questions. Why this Matters:
Important Questions This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020.
International Student Health Insurance Program (ISHIP) 2014-2015
2014 2015 Medical Plan Summary for International Students Translation Services If you need an interpreter to help with oral translation services, you may contact the LifeWise Customer Service team at 1-800-971-1491
HPN Solutions HMO 15 V2 $7/35/55
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myhpnonline.com or by calling (702) 242-7300 or 1-800-777-1840.
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
Administered by Capital BlueCross 1
Administered by Capital BlueCross 1 PPO HRA Plan/Rx Plan This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
Independent Health s Medicare Passport Advantage (PPO)
Independent Health s Medicare Passport Advantage (PPO) (a Medicare Advantage Preferred Provider Organization Option (PPO) offered by INDEPENDENT HEALTH BENEFITS CORPORATION with a Medicare contract) Summary
Health Care Plans - Which is the Most Deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.