: SimplyBlue GI - T1 without Maternity - S Coverage Period: Beginning on or after 07/01/2014
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1 : SimplyBlue GI - T1 without Maternity - S Coverage Period: Beginning on or after 07/01/2014 Summary of Benefits & Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO 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 or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? In-network: $1,500 person/$3,000 family Out-of-network: $3,000 person/$6,000 family Copays do not apply to the deductible. No. Yes. In-network: $6,500 person/$13,000 family Out-of-network: $19,500 person/$39,000 family Copays, premium, balancebilled charges, penalties, and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. You don't need a referral to see a specialist. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 7 at or call to request a copy.
2 Important Questions Answers Why this Matters: Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is Services You May Need Your cost if you use a In-Network Out-Of-Network Limitations & Exceptions Primary care visit to treat an injury or Office surgery is subject to 20% co-insurance 40% co-insurance illness deductible/coinsurance benefits. Specialist visit 20% co-insurance 40% co-insurance Office surgery is subject to deductible/coinsurance benefits. Other practitioner office visit 20% co-insurance 40% co-insurance Therapy limited to 20 visits per type per year. Cardiac/Pulmonary Rehab limited to 36 visits per type per year. Preventive care/screening/immunization No Charge 40% co-insurance none Diagnostic test (x-ray, blood work) 20% co-insurance 40% co-insurance none Prior Authorization required. Imaging (CT/PET scans, MRIs) 20% co-insurance 40% co-insurance Penalities include benefits limited to 50% of MAC or denial of claim. Generic drugs Not Covered Not Covered none Preferred brand drugs Not Covered Not Covered none Non-preferred brand drugs Not Covered Not Covered none 06/06/ :55 PM 2 of 7
3 Common Medical Event available at If you have outpatient surgery If you need immediate medical attention Services You May Need Your cost if you use a In-Network Out-Of-Network Limitations & Exceptions Self-Administered Specialty drugs Not Covered Not Covered none Facility fee (e.g., ambulatory surgery center) 20% co-insurance 40% co-insurance Physician/surgeon fees 20% co-insurance 40% co-insurance Prior Authorization required for certain outpatient procedures. Penalities include benefits limited to 50% of MAC or denial of claim. Prior Authorization required for certain outpatient procedures. Penalities include benefits limited to 50% of MAC or denial of claim. Emergency room services 20% co-insurance 20% co-insurance none Emergency medical transportation 20% co-insurance 20% co-insurance none Urgent care Urgent Care benefits are determined See Limitations & See Limitations & by place of service, such as Exceptions Exceptions physician's office or ER. Facility fee (e.g., hospital room) 20% co-insurance 40% co-insurance none If you have a hospital stay Physician/surgeon fee 20% co-insurance 40% co-insurance none Mental/Behavioral health outpatient If you have mental Not Covered Not Covered none services health, behavioral Mental/Behavioral health inpatient services Not Covered Not Covered none health, or substance abuse needs Substance use disorder outpatient services Not Covered Not Covered none Substance use disorder inpatient services Not Covered Not Covered none If you are pregnant Prenatal and postnatal care Not Covered Not Covered none Delivery and all inpatient services Not Covered Not Covered none If you need help Home health care 20% co-insurance 40% co-insurance Limited to 40 visits recovering or have Rehabilitation services 20% co-insurance 40% co-insurance Therapy limited to 20 visits per type other special health per year. Cardiac/Pulmonary Rehab needs Habilitation services 20% co-insurance 40% co-insurance limited to 36 visits per year. Skilled nursing care 20% co-insurance 40% co-insurance Skilled Nursing and Rehabilitation Facility limited to 30 days combined per Calendar Year. 06/06/ :55 PM 3 of 7
4 Common Medical Event If your child needs dental or eye care Language Access Services: Services You May Need Your cost if you use a In-Network Out-Of-Network Limitations & Exceptions Durable medical equipment 20% co-insurance 40% co-insurance Durable medical equipment over $500 requires Prior Authorization. Penalties include reduction of benefits or denial of claim. Hospice service No Charge 40% co-insurance Prior Authorization Required for Inpatient Hospice. Penalties include denial of claim. Eye exam Not Covered Not Covered none Glasses Not Covered Not Covered none Dental check-up Not Covered Not Covered none Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' /06/ :55 PM 4 of 7
5 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Infertility treatment Long-term care Pre and post-natal care and delivery, except Complications of Pregnancy Private-duty nursing Routine eye care (Adult) Routine foot care Services not covered due to Benefit Exclusion Riders Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Hearing aids for children under 18 Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at You may also contact your state insurance department at Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your state insurance department at Additionally, a consumer assistance program can help you file your appeal. Contact Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 06/06/ :55 PM 5 of 7
6 . About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $0 Patient pays $7,540 (This condition is not covered, so patient pays 100%.) Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $0 Co-insurance $0 Limits or exclusions $7,540 Total $7,540 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,160 Patient pays $2,240 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,500 Copays $0 Co-insurance $700 Limits or exclusions $40 Total $2,240 06/06/ :55 PM 6 of 7
7 : SimplyBlue GI - T1 without Maternity - S Coverage Period: Beginning on or after 07/01/2014 Coverage Examples Coverage for: Individual or Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. reimbursement your health plan allows. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 7 at or call to request a copy.
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LifeWise AC: UW GAIP+Vision/Dental Coverage Period: 10/01/2015 09/30/2016
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PENDING REGULATORY APPROVAL 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 sutterhealthplus.org or by calling
Even though you pay these expenses, they don t count toward the out-ofpocket limit.
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Cigna Health and Life Insurance Co.: mycigna Health Savings 3400 Coverage Period: 01/01/2014-12/31/14
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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.healthpartners.com or by calling 1-877-838-4949. Important
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$1,250person/ $2,500Family. Doesn t apply to preventive care. Important Questions. Why this Matters:
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Panther Gold Advantage: UPMC Health Plan Coverage Period: 07/01/2016-06/30/2017 Summary of Coverage: What this Plan Covers & What it Costs
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Cigna Health and Life Insurance Co.: mycigna Health Flex 1250 Coverage Period: 01/01/2014-12/31/14 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual&Family
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What is the overall deductible?
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Ultimate Full HMO for Small Business $25 Coverage Period: Beginning On or After 1/1/2014
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.blueshieldca.com or by calling 1-888-319-5999. Important
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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.chpstudent.com or by calling 1-800-633-7867. Important
LifeWise HP of Oregon: PST Silver HSA 3000 Coverage Period: Beginning on or after 01/01/2014
LifeWise HP of Oregon: PST Silver HSA 3000 Coverage Period: Beginning on or after 01/01/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: High-Deductible
Important Questions Answers Why this Matters: What is the overall deductible?
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Nationwide Life Insurance Co.: Gold Plan Roger Williams University Coverage Period: 8/14/15-8/13/16
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.chpstudent.com or by calling 1-800-633-7867. Important
Cigna Health and Life Insurance Company: NV Short Term Counseling: Coverage Period: 01/01/2014-12/31/2014
Cigna Health and Life Insurance Company: NV Short Term Counseling: Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual
Important Questions Answers Why this Matters: Non-Network $ 250 person / $ 500 family.
Lincoln Park Public Schools: Medical Benefits Coverage Period: 11/01/2012 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:
How To Know What Your Health Care Plan 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.bcbstx.com or by calling 1-800-521-2227. Important Questions
How to Choose a Health Care Plan
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DC37 Med Team PPO Plan Retirees
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: The Ohio State University 2015-1098-4 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: - 08/15/2016 This is only a summary. It in no way modifies your benefits as described in your plan documents. If you want more detail about your coverage and costs, you can get the complete
Important Questions Answers Why this Matters: $2,200 Does not apply to preventive care or amounts over the plan s allowable charge.
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.cernerhealth.com or by calling 1-877-765-1033. Important
Medical Billing - How Much Does Your Health Care Plan Cover?
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Trustmark Life Insurance Company: LewerMark Coverage Period: Beginning on or after Aug 1, 2015
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.lewermark.com or by calling 1-800-821-7710. Request a
Important Questions Answers Why this Matters:
Cigna Health and Life Insurance Co.: mycigna Copay Assure Silver Coverage Period: 01/1/2014-12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual&Family
The Ohio State University: Basic PPO Plan Coverage Period: 01/01/2015 12/31/2015
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 hr.osu.edu/hrpubs/ben/medicalspd.pdf or by calling 614-292-1050
Physicians Plus Insurance Corporation Coverage Period: 2015 Summary of Benefits and Coverage: WPE Traditional Uniform Benefits Plan Code: EHSTWWPE
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. Important Questions
BlueSelect 1449. No. Even though you pay these expenses, they don t count toward the out-of-pocket limit.
BlueSelect 1449 Coverage Period: 01/01/2015-12/31/2015 Everyday Health Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: PPO/EPO
Highmark Blue Shield: Flex Blue PPO 2100 a Community Blue 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 www.highmarkblueshield.com or by calling 1-888-510-1084.
Important Questions Answers Why this Matters: For in-network providers $0 person/ $0 family For out of-network providers $500 person/ $1,000 family
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State High Deductible Health Plan Non-Medicare Community Network
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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.blueshieldca.com or by calling 1-888-256-3520. Important
Florida Firefighters Insurance Trust Fund Coverage Period: 1/1/2015 12/31/2015
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.ffitf.com or by calling 1-800-664-5295. In the event
UPMC Advantage Enhanced Silver: UPMC Health Plan Coverage Period: Beginning on or after 01/01/2014
UPMC Advantage Enhanced Silver: UPMC Health Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All coverage levels Plan Type:
City of New York CBP Basic Program
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.emblemhealth.com or by calling 1-800-624-2414. Important
: Self-Funded Aetna Open Access Managed Choice HIGH DEDUCTIBLE HEALTH PLAN 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.healthreformplansbc.com or by calling 1-800-334-0299.
Important Questions Answers Why this Matters:
Cigna Health and Life Insurance Co.: mycigna Health Flex 2750 Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual&Family
Important Questions Answers Why this matters: What is the overall deductible?
Preferred Organization (PPO) 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.bcbsvt.com/vfp_cert or by
Cigna Health and Life Insurance Co.: mycigna Health Flex 2750 Coverage Period: 01/01/2014 12/31/2014
Cigna Health and Life Insurance Co.: mycigna Health Flex 2750 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual&Family
Sutter Health Plus: SG Silver Copay $45 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 sutterhealthplus.org or by calling 1-855-315-5800. Important
Highmark West Virginia: Blue Cross Blue Shield Shared Cost 1500, A Multi-State 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 www.highmarkbcbswv.com or by calling 1-888-601-2321 Important
TVA-Tennessee Valley Authority 80% PPO Plan Coverage Period: 01/01/2015-12/31/2015
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PPO Option 2: Highmark BCBS 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.highmarkbcbs.com or by calling 1-800-472-1506. Important
Important Questions Answers Why this Matters:
Harken Health Insurance Company: Care Gold II Coverage Period: Beginning on or after 1/1/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
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.empireblue.com/nyc or by calling 1-800- 433-9592. Important
Sutter Health Plus: SG Gold Copay $30 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 sutterhealthplus.org or by calling 1-855-315-5800. 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.healthnet.com or by calling 1-866-801-1446. 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.empireblue.com/nyc or by calling 1-800-767-8672 Important
Trustmark Life Insurance Company: NSU Coverage Period: Beginning on or after Aug 1, 2015
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.lewermark.com or by calling 1-800-821-7710. Important
Highmark Health Insurance Company: Shared Cost Blue PPO 5500
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.highmarkbcbs.com or by calling 1-800-544-6679. Important
WPE Coinsurance Uniform Benefits UW Health Network
WPE Coinsurance Uniform Benefits UW Health Network Coverage Period: 1/1/13-12/31/13 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family Plan Type:
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
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.healthnet.com or by calling 1-800-522-0088. Important
Important Questions Answers Why this Matters:
Sutter Health Plus: Schools Insurance Group_HDHP_HE06/HE56 Coverage Period: 07/01/2015 06/30/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete
Blue Shield of CA Life & Health Insurance: Shield Spectrum PPO SM 250-70/50 Foundation Coverage Period: 1/1/2014-12/31/2014
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.blueshieldca.com or by calling 1-800-200-3242. Important
Moda Health Plan, Inc.: Washington - Silver Be Prepared Coverage Period: 01/01/2014 12/31/2014
Coverage for: Individual + Family Plan Type: PPO 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.modahealth.com
Silver 70 HMO. 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.cchphmo.com or by calling 1-888-681-3888. Important Questions
Ultimate PPO Coverage Period: Beginning on or after 1/1/2014
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.blueshieldca.com or by calling 1-888-256-3650. Important
You can see the specialist you choose without permission from this 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 www.bcbsil.com or by calling 1-866-826-0913. Important Questions
Moda Health Plan, Inc.: Be Mighty (Select) (Bronze) Coverage Period: 01/01/2015 12/31/2015
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.modahealth.com or by calling 1-888-873-1395. 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.consumersmutual.org or by calling 1-877-371-9112. Important
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: HMO
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.emblemhealth.com or by calling 1-800-447-8255. Important
Kaiser Permanente: KP CA Bronze 5000/60
Kaiser Permanente: KP CA Bronze 5000/60 Coverage Period: Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Plan Type: HMO This is only a summary. If you want more detail
Blue Cross Blue Shield: Plus 3000 HSA High, a Multi-State Plan Coverage Period: 01/01/2016-12/31/2016
Blue Cross Blue Shield: Plus 3000 HSA High, a Multi-State Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual or
Coverage Period: 01/01/2014-12/31/2014 Coverage for: Family Plan Type: HDHP CA Technologies
Aetna Choice POS II - High Deductible Health 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 www.healthreformplansbc.com
BlueCare 1485. No. No. Yes. For a list of participating providers, see www.floridablue.com or call 1-800-352-2583.
BlueCare 1485 Coverage Period: 01/01/2016-12/31/2016 Everyday Health Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: HMO This is
Coverage for: Large Group Plan Type: HMO
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 sutterhealthplus.org or by calling 1-855-315-5800. 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.healthnet.com or by calling 1-800-522-0088. Important
Important Questions Answers Why this Matters: What is the overall 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.healthnet.com or by calling 1-800-522-0088. Important
Cigna Health and Life Insurance Company: mycigna CA Gold Plan Coverage Period: 1/1/2015-12/31/2015
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.mycigna.com or by calling 1-800-Cigna24. Important Questions
Highmark Blue Cross Blue Shield: PPOBlue Coverage Period: 08/01/2013-07/31/2014
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.highmarkbcbs.com or by calling 1-800-241-5704. 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.phxchoice.com or by calling 1-855-463-7275 (TTY: 1-855-463-7279).
BlueOptions 1424. In-Network: Not Applicable. Out-Of- Network: $500 Per Person. Does not apply to In-Network preventive care.
BlueOptions 1424 Coverage Period: 01/01/2016-12/31/2016 All Copay Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: PPO/EPO This
: State Teachers Retirement System Medicare Coverage Period: 01/01/2015-12/31/2015
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.aultcare.com or by calling 330-363-6360 or 1-800-344-8858.
Health Net Life Ins. Co.: PPO HSA C6B HD 1300/2600
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.healthnet.com or by calling 1-800-522-0088. Important
Important Questions Answers Why this Matters: $2,400 per individual / $4,800 per family Does not apply to preventive care and generic drugs.
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.blueshieldca.com or by calling 1-800-431-2809. Important
Fayette County Area Vo-Tech School: PPOBlue Coverage Period: 01/01/2015-12/31/2015
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.highmarkbcbs.com or by calling 1-800-241-5704. 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.healthnet.com/portal/shopping/content/iwc/shopping/contact_us.action
Highmark Blue Cross Blue Shield: PPO Coverage Period: 01/01/2015-12/31/2015
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.highmarkbcbs.com or by calling 1-800-241-5704. Important
Aetna Choice POS II - High Deductible Health Plan
- High Deductible Health Plan Important Questions Answers What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in
Coverage for: Individual/Family Plan Type: PPO
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 Marcia McMahon or by calling (814) 452-5673. Important Questions
Nationwide Life Insurance Company: Platinum Plan Option SUNY Buffalo State Coverage Period: 8/13/15-8/12/16
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.chpstudent.com or by calling 1-800-633-7867. Important
You can see the specialist you choose without permission from this plan.
: Business Advantage / Silver 1750 / HD Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family Plan Type: EPO This
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.healthnet.com or by calling 1-800-522-0088. Important
You can see the specialist you choose without permission from this 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 www.anthem.com or by calling 1-855-502-6365 Important Questions
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.cigna.com/individuals-families/california or by calling