2014 Summary of benefits plan comparison
|
|
- Alexander Morton
- 8 years ago
- Views:
Transcription
1 2014 Summary of benefits plan comparison The tables below summarize the 2014 Benefits for the Samaritan Choice Medical Plan options (Basic, Wellness and High-Deductible Plans). Pease refer to your plan document and/or your Summary of Material Modification for a detailed description of your benefits. Important Notice: All services apply to the deductible unless otherwise specified. Samaritan Choice Plan options In-network ONLY PREVENTIVE SERVICES (some of these services are not applied to your deductible & some services will not have a cost share) Well baby care $0 $0 $0 Routine physicals $0 $0 $0 Routine gynecological exams $0 $0 $0 Immunizations $0 $0 $0 Colonoscopy $0 $0 $0 PRIMARY CARE HOME (PCH) SERVICES In-Network Only (All eligible services that are rendered and billed by assigned Primary Care Homes (PCM) are $0 covered (No cost shares or deductibles apply) Primary Care Home (PCH) services $0 PROFESSIONAL SERVICES Primary care visits 1 $20 co-pay $30 co-pay $20 co-pay Specialist visits $35 co-pay $40 co-pay $35 co-pay Urgent care center visits $20 co-pay $30 co-pay $20 co-pay Surgery professional (at hospital) $50 co-pay $50 co-pay $50 co-pay CARE COORDINATION SERVICES For asthma, diabetes, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Chronic Obstructive Pulmonary Disease (COPD); does not apply to deductibles Office visit $0 $0 HEART HEALTH AND WELLBEING PROGRAM In-network services only. All eligible services that are rendered and billed by assigned Cardiac Prehab Coach are 100% covered only to those who are eligible for this Program. (No cost shares or deductibles apply) 1
2 Samaritan Choice Plan options In-network ONLY Cardiac services $0 EDUCATION SERVICES In-network providers only, regular cost-sharing is assessed for all out-of-network providers; does not apply to deductibles. Office visit for specified education services $0 $0 HOSPITAL / INPATIENT SERVICES Inpatient room and board Inpatient rehabilitative care Skilled Nursing Facility care $0 $0 $0 Bariatric surgery/ gastric banding (Lap band) surgery 2 OUTPATIENT SERVICES $5,000 co-pay $5,000 co-pay $5,000 co-pay Outpatient surgery (facility) $150 co-pay $250 co-pay $150 co-pay Emergency department visits (unless admitted to hospital) Diagnostic and therapeutic radiology and lab VALUE-BASED COST SERVICES In-Network only (Specified Surgical Procedures & High Tech Imaging) Specified surgical procedures (spine surgery for pain, arthroscopies, shoulder surgery for osteoarthritis) High tech imaging services (CT scans, MRIs and PET scans) $100 co-pay $100 co-pay $100 co-pay $0 10% $0 $400 co-pay 3,4 $200 co-pay 3,4 $500 co-pay 3,4 $200 co-pay 3,4 2
3 Samaritan Choice Plan options In-network ONLY MENTAL HEALTH AND CHEMICAL DEPENDENCY 3 Office visits $15 co-pay $15 co-pay $35 co-pay Inpatient care Residential programs 30% 30% 30% OTHER COVERED SERVICES Physical and occupational therapy $25 co-pay $25 co-pay $25 co-pay (combined limit/calendar year: $2,900) Samaritan physical therapy $20 co-pay $20 co-pay Speech therapy $25 co-pay $25 co-pay $25 co-pay (up to $2,900 limit/calendar year) Allergy injections (most) 6 $5 co-pay $5 co-pay $5 co-pay Injectables and other drugs administered other than orally (when rendered in the office) 6 10% 20% 10% Ambulance, ground 30% after $100 co-pay 30% after $100 co-pay 30% after $100 co-pay Ambulance, air 30% 30% 30% Durable Medical Equipment (DME) 30% 30% 30% Home health care $15 co-pay $15 co-pay $15 co-pay Hospice $0 $0 $0 Hearing aids $1,000 limit/year $1,000 limit/year $700 limit/year Acupuncture $35 co-pay $35 co-pay $35 co-pay Chiropractic 7 $25 12 visit limit/year $25 12 visit limit/year Panniculectomy 8 50% 50% 50%
4 1 Primary Care Provider visit is defined as services provided by a Pediatrics, Family Medicine, and Internal Medicine or OB-GYN provider. 2 Bariatric Surgery and Gastric Banding (Lap band) surgery co-pays do not apply to Out-of-Pocket Limit. 3 Co-pay does not apply if coded as Emergency s. Cost shares will default to normal benefit for Emergency s. 4 These Value-based co-pays do not count towards annual deductibles and Out-of-Pocket Limits. Regular co-payment or coinsurance must be separately paid as applicable. 5 OOP: Out-of Pocket Maximum or Limit Prescription drug benefits 6 Contact Customer s at (541) or to determine your co-pay or coinsurance levels for applicable services. 7 Chiropractic benefit only includes manipulation. This benefit does not include x-rays, labs, other radiology or other services that are not considered to be a manipulation treatment. 8 Panniculectomy coinsurance does not apply to Out-Of-Pocket Limit. s will only be covered when gastric bypass has been rendered by contracted provider. Therapeutic Generic Preferred Brand Non-Preferred $0 for: 7 specified generic drugs Selected Asthma medications Tobacco Cessation drugs/supplies Diabetic Insulin, Syringes, and Needles High-Cost Specialty drugs $7 or 20% whichever is greater $25 or 25% whichever is greater 50% 10% IMPORTANT NOTES: Over the Counter (OTC) medications will not be covered by Samaritan Choice Plans (SCP) without a prescription. Reference the Plan s formulary for more specific medication coverage. The Therapeutic benefit for the administration of insulin applies to all Samaritan Choice Plan options. All medications covered by SCP are subject to the Pharmacy & Therapeutics Committee and are approved to be on the formulary list of covered drugs. Reference the Plan s formulary for more specific medication coverage information. Annual individual and family deductibles Your annual deductibles Annual individual deductible $200 $400 $2,500 Annual family deductible $600 $1,000 $7,500 4
5 Out of pocket limits This is only a brief summary of benefits. Please refer to the additional information throughout this Plan Document for further explanations of your benefits including limitations and exclusions. Samaritan Choice Wellness Plan Per member $2,000 Per family $6,000 Samaritan Choice Basic Plan Per member $3,000 Per family $9,000 Samaritan Choice High-Deductible Plan Per member $4,000 Per family $12,000 Preferred and Non-preferred out-of-pocket max limits are combined. Pharmacy benefit has a separate out-of-pocket limit of $2,000 per person/calendar year for all plan options. 5
Cost Sharing Definitions
SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable
More informationHealth Insurance Matrix 07/01/012-06/30/13
Employee Contributions Family Monthly : $212.14 Bi-Weekly : $106.07 Monthly : $388.36 Bi-Weekly : $194.18 Monthly : $429.88 Bi-Weekly : $214.94 Monthly : $677.30 Bi-Weekly : $338.65 Employee Contributions
More informationHealth Insurance Matrix 01/01/16-12/31/16
Employee Contributions Family Monthly : $121.20 Bi-Weekly : $60.60 Monthly : $290.53 Bi-Weekly : $145.26 Monthly : $431.53 Bi-Weekly : $215.76 Monthly : $743.77 Bi-Weekly : $371.88 Employee Contributions
More informationHEALTH INSURANCE COMPARISON 2015-2016
Medical Plans no lifetime maximum on any medical plan PLAN- G PLAN G WITH GROUP HRA=PLAN C BENEFITS PLAN H (Currently Enrolled Employees Only) includes H.S.A deposit as per IRS rules Plan Year Costs- Deductibles
More informationOregon Nurses Association/Coquille Valley Hospital Comparison of Former and New Health Insurance Plan
2013-2014 Monthly Premium Employee Only Monthly Cost $628.11 Monthly Cost $396.95 Employee and Spouse Monthly Cost $1,444.67 Monthly Cost $873.30 Employee and Children Monthly Cost $1,155.73 Monthly Cost
More information2015 Health Benefits
2015 Health Benefits Product Cost Sharing - Member's Responsibility Health Care Reform Compliant Health Care Reform Compliant Health Care Reform Compliant Deductible (DED) (Per Person/Family Aggregate)
More informationCoventry Health and Life Insurance Company PPO Schedule of Benefits
State(s) of Issue: Oklahoma PPO Plan: OI08C30050 30 Coventry Health and Life Insurance Company PPO Schedule of Benefits Covered Services Contract Year Deductible For All Eligible Expenses (unless otherwise
More informationBenefit Summary - A, G, C, E, Y, J and M
Benefit Summary - A, G, C, E, Y, J and M Benefit Year: Calendar Year Payment for Services Deductible Individual $600 $1,200 Family (Embedded*) $1,200 $2,400 Coinsurance (the percentage amount the Covered
More informationWhat is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No.
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
More informationSummary of PNM Resources Health Care Benefits Active Employees 2011
of PNM Resources Health Care Benefits Active Employees 2011 The following charts show deductibles, limits, benefit levels and amounts for the PNM Resources medical, dental and vision programs. For more
More informationHealth Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.
Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.
More informationPhysicians Plus Insurance Corporation 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.pplusic.com or by calling 1-800-545-5015. Important Questions
More informationThe State Health Benefits Program Plan
State of New Jersey Department of the Treasury Division of Pensions and Benefits STATE HEALTH BENEFITS PROGRAM PLAN COMPARISON SUMMARY FOR STATE EMPLOYEES EFFECTIVE APRIL 1, 2008 (March 29, 2008 for State
More informationPPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20
PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA2000-20 Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when
More information2015 Medical Plan Summary
2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is
More informationSherwin-Williams Medical, Prescription Drug and Dental Plans Plan Comparison Charts
Sherwin-Williams Medical, Prescription Drug and Dental Plans Plan Comparison Charts You and Sherwin-Williams share the cost of certain benefits including medical and dental coverage and you have the opportunity
More informationPPO Insured Standard Network Deductible
BENEFIT HIGHLIGHTS Prepared for City of Seguin- Active BlueChoice Network This is a general summary of your benefits. Please refer to your Summary of and Coverage (SBC), or you may request a copy of the
More informationSERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 3838 N. Causeway Blvd. Suite 3350 Metairie, LA 70002 1-800-341-6613 SCHEDULE OF BENEFITS BENEFITS AND PRIOR AUTHORIZATION REQUIREMENTS ARE SET FORTH IN ARTICLES
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Violet Option 3 (PPO) Douglas and Josephine counties, OR Benefits effective January 1, 2016 H5520 Health Net Life Insurance Company H5520_2016_0202 CMS Accepted 09162015
More informationFIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)
FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties 1 P age SECTION I - INTRODUCTION TO SUMMARY
More informationImportant 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.samhealth.org/healthplansor by calling 1-800-832-4580.
More informationAVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible
AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific
More informationYour 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
More informationIndependent 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
More informationSummary of Benefits Community Advantage (HMO)
Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
More informationPPO-Insured-Standard-with Network Deductible
B E N E F I T H I G H L I G H T S P r e p a r e d f o r T T U H S C - E L P A S O a n d O D E S S A B l u e C h o i c e N e t w o r k This is a general summary of your benefits. Please refer to your benefit
More informationWhat 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.anthem.com/cuhealthplan or by calling 1-800-735-6072.
More information[2015] SUMMARY OF BENEFITS H1189_2015SB
[2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare
More informationHNE 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
More informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits UPMC Consumer Advantage HSA PPO - Premium Network Primary Care Provider: 10% after Deductible Specialist: 10% after Deductible Deductible: $1,950 / $3,900 Rx: 10% after Deductible
More informationHealthy Benefits HMO 6850.0
Coverage Period: Beginning on or after 1/1/2016 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 https://www.capbluecross.com/sbcsia
More informationWestern Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/2016-12/31/2016
Coverage For: Self 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.westernhealth.com or
More informationLand of Lincoln Health : Family Health Network LLH 3-Tier Bronze PPO 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.landoflincolnhealth.org or by calling 1-844-FHN-4YOU.
More informationAssurant Health. Time Insurance Company. Summary of Benefits and Coverage for Assurant Health individual major medical Silver plans
Assurant Health Time Insurance Company Summary of Benefits and Coverage for Assurant Health individual major medical Silver plans View Summary of Benefits and Coverage for an individual plan View Summary
More informationHow Much Does Your Health Care Plan Cover?
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.arml.org\benefit_programs.html or by calling 1-501-978-6137.
More informationHighlights 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
More informationSchedule of Medical Benefits: State Participants 2015
I. Schedule of Medical Benefits Schedule of Medical Benefits: State Participants 2015 All benefits are paid according to the terms of the Master Contract between the Health Plan and Pharmacy Benefit Manager
More informationSummary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711)
Summary of s and January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE For more information about benefits or enrollment, call us or visit our website at www.martinspoint.org/medicare. 1-888-408-8285
More informationBlue Cross Premier Bronze Extra
An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network
More informationNational PPO 1000. PPO Schedule of Payments (Maryland Small Group)
PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer
More informationWhat is the overall deductible? Are there other deductibles for specific services?
: MyPriority POS RxPlus Silver 1800 Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Subscriber/Dependent Plan Type:
More informationS 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
More informationHealth Plans Comparison Chart
Health Plans Comparison Chart PPO Deductible Coinsurance (Plan pays) Annual Out-of-Pocket Maximum (Medical) (all medical s, deductibles and coinsurance for covered services will apply. Once limit is met,
More informationSenate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***
Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350
More informationBowling Green State University : Plan B 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 MedMutual.com/SBC or by calling 800.540.2583. Important Questions
More informationSummary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)
Summary of Benefits January 1, 2016 December 31, 2016 FIRSTCAROLINACARE INSURANCE COMPANY FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties This booklet
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
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
More informationOperating Engineers Public Employees Health and Welfare Trust Fund Plan D vs PERS CHOICE and PERS SELECT PPO Plan
Calendar Year Deductible $500 Individual / $1,000 Family per calendar year Does not apply to PPO physician office visits, PPO preventive care or hospital emergency room charges for an emergency medical
More informationROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area
Contacting the Carrier Voice: (877) 883-9577 TTY: (585) 454-2845 Website: Voice: (800) 665-7924 TTY: (800) 252-2452 Website: www.excellusbcbs.com www.mvphealthcare.com Deductible Carry Over None None Deductible,
More information2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
More informationS 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
More informationGundersen Health Plan: MN NJ Silver $2000-0% 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.gundersenhealthplan.org or by calling 1-800-897-1923.
More informationAdministered 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
More informationJanuary 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1
January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we
More informationImportant Questions Answers Why this Matters: Preferred Provider: $1,000 per Person/2,000 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.wpsic.com or by calling 1-888-915-4001. Important Questions
More informationCoverage for: Large Group Plan Type: HMO
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
More informationImportant Questions Answers Why this Matters:
UnitedHealthcare Life Ins Co: Platinum Copay Select Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family
More informationMedical Plan Comparison - Retirees Age 65 or Over
* Plan Type Medicare Cost Plan with Prescription Coordinates with Medicare and includes Medicare prescription drug program Medicare Cost Plan with Prescription Medicare Advantage Plan with Prescription
More information2015 Summary of Benefits
2015 Summary of Benefits Value (HMO-POS) Essentials Rx (HMO-POS) (H4270) January 1, 2015 - December 31, 2015 Western Wisconsin (26 Counties) H4270_082914_1 CMS Accepted (09032014) SECTION I INTRODUCTION
More information2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
More information$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other. deductibles for specific No.
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 capbluecross.com or by calling 1-800-730-7219. Important
More informationJanuary 1, 2015 December 31, 2015
BLUESHIELD FOREVER BLUE MEDICARE PPO VALUE AND BLUESHIELD MEDICARE PPO 750 (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
More informationImportant 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 https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.
More informationImportant 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.etf.wi.gov or by calling 1-877-533-5020. Important Questions
More informationHEALTH 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
More information$250 copay per admit. $250 copay per admit
BENEFIT IN- NETWORK OUT- OF- NETWORK Deductible NONE NONE Out- of- Pocket Maximum $6,350 Single/ $12,700 Family NONE HOSPITAL INPATIENT FACILITY - NON MATERNITY Medical/Surgical Skilled Nursing Facility
More informationConsumers 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
More informationCoverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. 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.gallagherkoster.com/colgate or by calling 1 877-371-9621.
More information2015 Summary of Benefits
2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list
More informationWhat is the overall deductible? Are there other deductibles for specific services?
Small Group Agility MS200 Coverage Period: Beginning on or after 01/01/2015 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
More informationCoverage for: Individual, Family Plan Type: PPO. 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.bbsionline.com or by calling 1-866-927-2200. Important
More informationIndividual Plan: Silver 1 93-95 Coverage Period: 01/01/2014-12/31/2014
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.cchpsc.org or by calling 1-800-580-8736 or TTY 1-800-545-8279
More informationPace University CIGNA Medical Detailed Benefit Summaries July 1, 2015 - June 30, 2016
Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Deductible $1,300/$2,600 (Cumulative) N/A N/A Coinsurance
More informationCoverage for: Individual Plan Type: PPO. 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.chpstudent.com or by calling 1-800-633-7867. Important
More informationSummary Table of Benefits Select Medicare Supplement Plan
2016 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare
More informationLGC 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
More informationSummary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma
Summary of Benefits 2016 HMO King, Pierce, Snohomish, Spokane and Thurston Counties premera.com/ma Plus Section 1 Introduction to the and Plus This booklet gives you a summary of what we cover and what
More informationImportant Questions Answers Why this Matters:
Anthem BlueCross BlueShield Blue Access PPO Option D58 / Rx Option 8 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family
More informationCoverage level: Employee/Retiree Only Plan Type: EPO
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 documents at www.dbm.maryland.gov/benefits or by calling 410-767-4775
More informationCigna Open Access Plans for Tennessee
Individual & Family Plans Insured by Connecticut General Life Insurance Company Cigna Open Access Plans for Tennessee medical & PHARMACY INSURANCE with the ONE-AND-ONLY YOU IN MIND. 858436 a 12/12 Services
More informationAnthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO
Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with
More informationStudentBlue University of Nebraska
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more details about
More information2015 Summary of Benefits
2015 Summary of Benefits January 1, 2015 December 31, 2015 Houston/Beaumont Area Y0067_PRE_H4506_SETX_SB41_0814 CMS Accepted 09/13/2014 HMO-SETX-SB K41 2015 Section I Introduction to Summary of Benefits
More informationYou 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.pekininsurance.com or by calling 1-800-371-9622. Important
More informationUnited Healthcare Insurance - Summary of Benefits and Costs
UnitedHealthcare Life Ins Co: Platinum Copay Select Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family
More informationImportant 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.cfhp.com or by calling 1-800-434-2347. Important Questions
More informationHealth Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary
5 Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Plans Medicare members, by plan. Topics: Health
More informationSummary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015. HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595
Summary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015 HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595 For Medicare-eligible beneficiaries residing in Arenac, Bay,
More information$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific
This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.teamsters-hma.com or by calling 1-866-331-5913.
More informationHealth Partners Plans Provider Manual Health Partners Medicare Benefits Summary
5 Health Partners Plans Provider Manual Health Partners Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Medicare members, by plan. Topics: Health Partners
More informationDelta College 007000338-0001, 0002, 0003, 0004, 0005, 0006, 0007 Community Blue SM PPO Medical Coverage Benefits-at-a-Glance
Delta College 007000338-0001, 0002, 0003, 0004, 0005, 0006, 0007 Community Blue SM PPO Medical Coverage Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview
More informationSTATE OF IOWA HEALTH INSURANCE PLAN COMPARISON EFFECTIVE JANUARY 1, 2016
This comparison is only a summary of benefits. Benefits will be administered as described in each plan s Summary of Benefits & Coverage. For further details, refer to those documents or call Wellmark Blue
More informationInternational 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
More informationHealth Plans That Fit Your Life 2016
Health Plans That Fit Your Life 2016 Maine 121415-02-0004 Find the one that s right for you. Certified by the Health Insurance Marketplace My husband and I both work for ourselves so Health Options has
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
Molina Healthcare of Ohio, Inc.: Molina Gold Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family ǀ Plan
More informationLand of Lincoln Health : Chicago Health System LLH Silver 0622 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.landoflincolnhealth.org or by calling 1-844-674-3834.
More informationTribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP
Tribute Health Plan of Oklahoma Tribute Health Plan of Oklahoma HMO SNP 2015 Summary of Benefits This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
More informationBlueCross BlueShield of North Carolina: Blue Advantage Platinum 500 (broad network)
BlueCross BlueShield of North Carolina: Blue Advantage Platinum 500 (broad network) $$start$$ Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
More informationSummaries of Benefits and Coverage
Summaries of Benefits and Coverage Tufts Health Direct ConnectorCare Plan Type I Tufts Health Direct ConnectorCare Plan Type II Tufts Health Direct ConnectorCare Plan Type III Tufts Health Direct Silver
More informationLesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip
HOSPITAL SERVICES Hospital Inpatient : Paid in full, Non-network: Hospital charges subject to 10% of billed charges up to coinsurance maximum. Non-participating provider charges subject to Basic Medical
More information