Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges."

Transcription

1 Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges. COLORADO As your partner in health, we want to help you manage your health care spending. Knowing how much you can expect to pay for care and services can give you peace of mind so you can concentrate on the things you enjoy in life. This Sample Fee List shows you estimated charges 2 for many common medical services like office visits, lab tests, and X-rays when you receive care at Kaiser Permanente facilities. Your charges may be different if you receive care or services from a contracted provider at a non Kaiser Permanente facility. This list doesn t apply to medical services received from any network providers who aren t Kaiser Permanente providers. The amount you pay out of your own pocket for a service will depend on your plan coverage, whether you ve reached your deductible or out-of-pocket maximum, and other factors. The amount you are asked to pay may be a copay (a fixed dollar amount you pay for services) or coinsurance (a percentage of charges you pay for services). Please note that these estimated charges are based on typical visits. Your actual charges may vary depending on your diagnosis and the length of your visit. Use this Sample Fee List to help with the following: Review your benefit options during open enrollment. If you have a choice of plans, the amount you pay out of your own pocket for care may vary, so knowing how much services cost can help you choose the best Kaiser Permanente plan for you. Estimate how much you ll spend throughout the year for care and services at our facilities. Manage funds in your health savings account (HSA) or health reimbursement arrangement (HRA) to cover upcoming medical services. 3 Estimate the funds you may need for your flexible spending account (FSA), and manage them throughout the year. For more information about your benefits, please call Member Services or Customer Service at the number provided on your ID card. For cost estimates for a specific medical service or to ask about payment plans or other financial assistance, please contact Financial Counseling at This Sample Fee List does not apply to medical services received from any network providers who are not Kaiser Permanente providers. 2 The estimated member charges in this Sample Fee List are valid as of January 1, 2015, and may change without notice. 3 You must be enrolled in an HSA-qualified deductible plan or a deductible plan with HRA to use this feature. If you are enrolled through a group s self-funded plan, your health benefits are self-insured by your employer, union, or Plan sponsor. Kaiser Permanente Insurance Company provides certain administrative services for the Plan and is not an insurer of the Plan or financially liable for health care benefits under the Plan.

2 Office Visits New patient visit, level 1 (low severity) - Primary Care $59 New patient visit, level 1 (low severity) - Specialty Care $65 New patient visit, level 2 - Primary Care $101 New patient visit, level 2 - Specialty Care $111 New patient visit, level 3 - Primary Care $147 New patient visit, level 3 - Specialty Care $161 New patient visit, level 4 - Primary Care $225 New patient visit, level 4 - Specialty Care $247 New patient visit, level 5 (high severity) - Primary Care $280 New patient visit, level 5 (high severity) - Specialty Care $308 Established patient visit, level 1 (low severity) - Primary Care $27 Established patient visit, level 1 (low severity) - Specialty Care $30 Established patient visit, level 2 - Primary Care $59 Established patient visit, level 2 - Specialty Care $65 Established patient visit, level 3 - Primary Care $99 Established patient visit, level 3 - Specialty Care $109 Established patient visit, level 4 - Primary Care $146 Established patient visit, level 4 - Specialty Care $161 Established patient visit, level 5 (high severity) - Primary Care $195 Established patient visit, level 5 (high severity) - Specialty Care $215 Office Visits (Preventive) Well-baby office visit, new patient (under 1 year)* $150 Well-child office visit, new patient (1 4 years)* $157 Well-child office visit, new patient (5 11 years)* $163 Well-child office visit, new patient (12 17 years)* $185 Well-adult office visit, new patient (18 39 years)* $179 Well-adult office visit, new patient (40 64 years)* $207 Well-adult office visit, new patient (65 and older)* $225 Well-baby office visit, established patient (under 1 year)* $135 Well-child office visit, established patient (1 4 years)* $145 Well-child office visit, established patient (5 11 years)* $144 Well-child office visit, established patient (12 17 years)* $158 Well-adult office visit, established patient (18 39 years)* $161 Well-adult office visit, established patient (40 64 years)* $172 Well-adult office visit, established patient (65 and older)* $185 These estimated member charges are valid as of January 1, 2015, and may change without notice. 2

3 Specialist Consultations Office consultation $66 Specialist visit, long $252 Specialist visit, short $125 Specialist visit, typical $170 Emergency Visits Emergency care by physician, level 1 (low severity) $93 Emergency care by physician, level 2 $141 Emergency care by physician, level 3 $235 Emergency care by physician, level 4 (high severity) $350 Psychotherapy Visits Group psychological therapy $42 Psychiatric diagnostic interview exam $215 Therapy $138 Eye Examinations Eye exam, routine visit, new patient $116 Eye exam and treatment, new patient $210 Eye exam, routine visit, established patient $121 Eye exam and treatment, established patient $175 Intermediate eye exam, new patient and refraction $144 Intermediate eye exam, established patient and refraction $149 Vision screening test $5 Hearing Services Comprehensive audiometry evaluation $61 Ear cleaning $78 Eardrum test $24 Hearing screening test (pure tone, air only) $19 Physical Therapy Services Electric stimulation therapy, treatment only $29 Physical therapy evaluation $137 Physical therapy, exercises, treatment only $58 Physical therapy, hot and cold application, treatment only $10 Physical therapy, ultrasound, treatment only $21 These estimated member charges are valid as of January 1, 2015, and may change without notice. 3

4 Vaccines and Other Injections Allergy shot $14 Chickenpox vaccine* $120 Diphtheria, tetanus booster vaccine* $34 Diphtheria, tetanus, pertussis vaccine* $41 Flu shot, children (3 years and older)* $25 Flu shot, infants* $10 Hepatitis B vaccine* $96 Intravenous push, single or initial substance/drug $91 Measles, mumps, and rubella vaccine* $81 Pneumococcal vaccine* $129 Polio vaccine* $46 Respiratory syncytial virus* $255 Rubella vaccine* $43 Therapeutic injection (administration only, does not include medication) $40 Therapeutic intravenous injection (administration only, does not include medication) $31 Vaccine administration, adult $40 Zoster vaccine* $261 Tests and Procedures Breathing capacity test $58 Breathing treatment $29 Colonoscopy and removal of abnormal tissue using cautery* $732 Colonoscopy and removal of abnormal tissue using snare technique* $826 Colonoscopy and removal of colon tissue for examination* $732 Diagnostic colonoscopy* $615 Diagnostic proctosigmoidoscopy $194 Diagnostic sigmoidoscopy $215 Draining fluid from around swollen joint $95 Electrocardiogram (EKG) $27 Electromyogram (EMG), one extremity $196 Fetal monitoring $78 Loop electrosurgical excision procedure (LEEP) $464 Removal of abnormal areas of skin $10 Sigmoidoscopy and removal of tissue for examination $258 Skin biopsy $160 (continues) These estimated member charges are valid as of January 1, 2015, and may change without notice. 4

5 Tests and Procedures (continued) Skin biopsy (each additional lesion within same visit) $51 Stress test $122 Surgically destroying an abnormal area of skin $35 Ultrasound test of heart $213 Vasectomy $599 X-rays, CT Scans, and Other Imaging Studies CT scan of chest, including dye $681 CT scan of pelvis, including dye $670 CT scan of pelvis, without dye $430 CT scan of sinus and nasal passages $578 CT scan of stomach area, with dye $683 CT scan of stomach area, without dye $440 DXA bone density scan, peripheral $44 DXA bone density scan, vertebral fracture $14 Mammogram $184 Mammogram (one side) $143 Mammogram (screening) $131 MRI of any joint of the lower extremity, without dye $726 MRI of any joint of the upper extremity, without dye $725 MRI of brain, including dye $949 MRI of brain, without dye $697 MRI of brain, without dye, followed by further sequences including dye $1,119 MRI, abdomen, with contrast $1,322 MRI, abdomen, without contrast $959 MRI, abdomen, without contrast, followed by with contrast $1,479 MRI, angiogram, pelvis $1,196 MRI, cervical spine, with contrast $952 MRI, cervical spine, without contrast $692 MRI, cervical spine, without dye, followed by further sequences including dye $1,120 MRI, head, with contrast $1,137 MRI, head, without contrast $1,004 MRI, lower extremity $1,467 MRI, lumbar spine, with contrast $940 MRI, lumbar spine, without contrast $693 (continues) These estimated member charges are valid as of January 1, 2015, and may change without notice. 5

6 X-rays, CT Scans, and Other Imaging Studies (continued) MRI, lumbar spine, without dye, followed by further sequences including dye $1,117 MRI, neck, with contrast $1,214 MRI, neck, without contrast $1,004 MRI, thoracic spine, with contrast $943 MRI, thoracic spine, without contrast $692 MRI, thoracic spine, without dye, followed by further sequences including dye $1,121 MRI, upper extremity $1,459 Pregnancy ultrasound $235 Review of CT scan of head or brain $352 Ultrasound of breast $44 Ultrasound of pelvis $200 Ultrasound of stomach area $227 Vaginal ultrasound $203 X-ray for osteoporosis* $79 X-ray of abdomen (complete) $80 X-ray of ankle $47 X-ray of ankle (complete) $57 X-ray of both knees $58 X-ray of chest $50 X-ray of chest (one view interpretation) $38 X-ray of finger $54 X-ray of foot $44 X-ray of foot (complete) $54 X-ray of hand $45 X-ray of hand (complete) $54 X-ray of hip $64 X-ray of knee $53 X-ray of knee (complete) $71 X-ray of lower back bones $59 X-ray of neck $79 X-ray of neck bones $59 X-ray of shoulder $53 X-ray of stomach area (one view) $40 X-ray of wrist (complete) $62 X-ray of wrist (two views) $51 These estimated member charges are valid as of January 1, 2015, and may change without notice. 6

7 Laboratory Tests Albumin test $11 Alkaline phosphatase test $11 Allergy test $10 ALT liver function test $12 Amylase test $14 AST liver function test $11 Bilirubin test (total) $11 Blood antibody test $9 Blood clotting test $9 Blood sugar test, diagnostic $9 Blood sugar test, monitoring $21 Calcium test (total) $11 Cholesterol level test* $9 Complete blood count $15 Creatinine test $11 Hepatitis B surface antigen test $23 Hepatitis C test* $31 Kidney function test $9 Laboratory chemistry test for creatine kinase $14 Lipid panel test* $29 Magnesium test $15 Pap test, cervical cancer screening* $23 Phosphorus test $10 Potassium test $10 Pregnancy test $15 Prostate test* $40 Sodium test $11 Strep-A-Swab test $44 Test for blood in stool* $7 Test for genital warts $0 Thyroid stimulating hormone test $37 Urine bacteria colony count $18 Urine test (complete) $7 Urine test (dipstick only) $5 Urine test (microanalysis only) $7 These estimated member charges are valid as of January 1, 2015, and may change without notice. 7 Please recycle January 2015

Kaiser Permanente 2016 Sample Fees List 1

Kaiser Permanente 2016 Sample Fees List 1 Kaiser Permanente 2016 Sample Fees List 1 SOUTHERN CALIFORNIA Knowing how much you can expect to pay for care and services can give you peace of mind. This Sample Fees List shows you estimated fees for

More information

Kaiser Permanente 2011 Sample Fee List Members in any deductible plan can use the sample fee list to estimate charges.

Kaiser Permanente 2011 Sample Fee List Members in any deductible plan can use the sample fee list to estimate charges. Kaiser Permanente 2011 Sample Fee List Members in any deductible plan can use the sample fee list to estimate charges. Colorado AREA As your partner in health, we want to help you better manage your care.

More information

Kaiser Permanente 2016 Sample Fee List *

Kaiser Permanente 2016 Sample Fee List * Kaiser Permanente 2016 Sample Fee List * NORTHWEST What s a Sample Fee List? Knowing how much you can expect to pay for care and services can help give you peace of mind. As a deductible plan member, you

More information

Kaiser Permanente 2015 Sample Fee List 1

Kaiser Permanente 2015 Sample Fee List 1 Kaiser Permanente 2015 Sample Fee List 1 NORTHERN CALIFORNIA As your partner in health, we want to help you manage your health care spending. Knowing how much you can expect to pay for care and services

More information

Kaiser Permanente 2016 Sample Fee List *

Kaiser Permanente 2016 Sample Fee List * Kaiser Permanente 2016 Sample Fee List * What s a Sample Fee List? SOUTHERN CALIFORNIA Knowing how much you can expect to pay for care and services can help give you peace of mind. As a deductible HMO

More information

Kaiser Permanente Sample Fee List

Kaiser Permanente Sample Fee List Kaiser Permanente Sample Fee List SOUTHERN CALIFORNIA As your partner in health, we want to help you better manage your care. Staying on top of your finances, related to how much you spend on health care,

More information

MHDO CompareMaine Updated: 9/17/2015

MHDO CompareMaine Updated: 9/17/2015 Office Visits -- Adult Preventative Care Office Visit (or Wellness Office Visit) 99385 New patient preventive care visit for adult, ages 18 to 39 99386 New patient preventive care visit for adult, ages

More information

CATEGORY AFSCME Comprehensive Plan OU PPO

CATEGORY AFSCME Comprehensive Plan OU PPO APPENDIX B BENEFIT PLAN SUMMARY CHART CATEGORY AFSCME Comprehensive Plan OU PPO Premiums 2010-2011 Plan Year 2010-2011 Plan Year Annual Wages: $0 - $34,600 $13.50 EE only $24.00 EE + Child $24.00 EE +

More information

Prevents future health problems. You receive these services without having any specific symptoms.

Prevents future health problems. You receive these services without having any specific symptoms. Preventive Care To help you live the healthiest life possible, we offer free preventive services for most Network Health members. Please refer to your member materials, which you received when you enrolled

More information

Preventive health guidelines As of May 2014

Preventive health guidelines As of May 2014 To learn more about your plan, please see anthem.com/ca. To learn more about vaccines, please see the Centers for Disease Control and Prevention (CDC) website: cdc.gov. Preventive health guidelines As

More information

PASSPORT TO WOMEN S HEALTH

PASSPORT TO WOMEN S HEALTH PASSPORT TO WOMEN S HEALTH Introduction W omen are extraordinary. Daughters, sisters, mothers, aunts, cousins, friends, wives. Saint John s Health Center recognizes the importance of women and that women

More information

Michigan Electrical Employees Health Plan Benefits & Eligibility-at-a Glance Supplement to Medicare - Medicare Enrollees

Michigan Electrical Employees Health Plan Benefits & Eligibility-at-a Glance Supplement to Medicare - Medicare Enrollees Medicare Coverage BCBSM Supp Coverage Preventive Services 12 months, if age 50 and older Colonoscopy - one per calendar year 1 0 years (if at high risk every 24 months) approved amount**, once per flu

More information

THE CLEVELAND CLINIC. personal. Health. Management. Program

THE CLEVELAND CLINIC. personal. Health. Management. Program THE CLEVELAND CLINIC personal Health Management Program Our Personal Health Management Program offers a comprehensive examination in a package tailored to meet your unique medical needs. Expert Care The

More information

Preventive health guidelines As of May 2015

Preventive health guidelines As of May 2015 Preventive health guidelines As of May 2015 What is your plan for better health? Make this year your best year for wellness. Your health plan may help pay for tests to find disease early and routine wellness

More information

PREVENTIVE CARE SERVICES Detailed descriptions

PREVENTIVE CARE SERVICES Detailed descriptions PREVENTIVE CARE SERVICES Detailed descriptions How often and what kind of preventive care services you need depends upon your age, gender, health and family history. Not all items on this list are covered

More information

Preventive health guidelines

Preventive health guidelines Preventive health guidelines As of May 2015 What is your plan for better health? Make this year your best year for wellness. Your health plan may help pay for tests to find disease early and routine wellness

More information

Preventive Health Services

Preventive Health Services understanding Preventive Health Services For the most current version of this document, visit www.wellwithbluemt.com or www.bcbsmt.com. Preventive health services include evidence-based screenings, immunizations,

More information

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:

COVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions: Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization,

More information

Summary of Benefits Community Advantage (HMO)

Summary 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 information

2015 Medicare Advantage Summary of Benefits

2015 Medicare Advantage Summary of Benefits 2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015

More information

-----------------None-------------------------------

-----------------None------------------------------- This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet twww.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

Summary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma

Summary 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 information

Health care reform update

Health care reform update Preventive services coverage Kaiser Foundation Health Plan of the Northwest has always offered broad, affordable coverage options that encourage members to seek care before a health condition becomes serious.

More information

Preventive Health Guidelines

Preventive Health Guidelines Preventive Health Guidelines As of April 2010 What is your plan for better health? Make this year your best year for overall wellness. Your health benefits plan may cover early detection screenings and

More information

Health Plans Coverage Summary

Health Plans Coverage Summary www.hr.msu.edu/openenrollment Faculty & Staff Health Plans Coverage Summary PREVENTIVE SERVICES Health Maintenance Exam (1) Annual Gynecological Exam Pap Smear Screening (lab services only) Mammography

More information

myhealthcare Cost Estimator (myhce)

myhealthcare Cost Estimator (myhce) myhealthcare Cost Estimator (myhce) myhealthcare Cost Estimator By the Numbers 99.5% of our consumers Have access to personalized estimates 635+ / 365+ Unique services / treatments covered $2.8 Billion

More information

Organize Your Family's Health Care with this Checklist of Routine Physical Exams and

Organize Your Family's Health Care with this Checklist of Routine Physical Exams and All adults should visit their health care provider from time to time, even if they are healthy. The purpose of these visits is to: Screen for diseases Assess risk of future medical problems Encourage a

More information

[2015] SUMMARY OF BENEFITS H1189_2015SB

[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 information

Preventive Care Recommendations THE BASIC FACTS

Preventive Care Recommendations THE BASIC FACTS Preventive Care Recommendations THE BASIC FACTS MULTIPLE SCLEROSIS Carlos Healey, diagnosed in 2001 The Three Most Common Eye Disorders in Multiple Sclerosis Blood Pressure & Pulse Height & Weight Complete

More information

Health Care Administrators

Health Care Administrators Health Care Administrators January 21, 2005 Depend on HCA to be your resource for news and information. Page 1 of 2 1 Important Clarifications Related to Health Savings Accounts You ve asked for more information

More information

An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits

An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits The chart below presents the list of benefits covered by Medicare, and

More information

2016 Mayo Clinic Health System Eau Claire Charge and Reimbursement Information for Health Care Consumers Required by 2009 Wisconsin Act 146

2016 Mayo Clinic Health System Eau Claire Charge and Reimbursement Information for Health Care Consumers Required by 2009 Wisconsin Act 146 2016 Mayo Clinic Health System Eau Claire Charge and Reimbursement Information for Health Care Consumers Required by 2009 Wisconsin Act 146 The Wisconsin Act 146 seeks to make cost and charge information

More information

CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance

CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview

More information

Medicare Options For Retiree/Direct Bill Members

Medicare Options For Retiree/Direct Bill Members Open Enrollment 2014 State Employee Health Plan Medicare Options For Retiree/Direct Bill Members Comparison Chart 2 2013 **Cover photo is titled Road into the Field from the Postcards from Kansas collection

More information

Member s responsibility (deductibles, copays, coinsurance and dollar maximums)

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

More information

2015 Summary of Benefits

2015 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 information

2012 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado Ded/Co HMO 1200D Denver/Boulder Small Group

2012 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado Ded/Co HMO 1200D Denver/Boulder Small Group PART A: TYPE OF COVERAGE 2012 Colorado Health Benefit Plan Description Form Ded/Co HMO 1200D Denver/Boulder Small Group 1. TYPE OF PLAN Health Maintenance Organization (HMO) 2. OUT-OF-NETWORK CARE COVERED?

More information

-----------------None-------------------------------

-----------------None------------------------------- This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1

January 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 information

Coverage for preventive care

Coverage for preventive care Coverage for preventive care Understanding your preventive care coverage Preventive care, like screenings and immunizations, helps you and your family stay healthier and can help lower your overall out-of-pocket

More information

2015 Summary of Benefits

2015 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 information

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)

FIRSTCAROLINACARE 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 information

2016 Guide to Understanding Your Benefits

2016 Guide to Understanding Your Benefits 2016 Guide to Understanding Your Benefits Additional information about covered benefits available from Health Net Healthy Heart (HMO) Plan Alameda, Stanislaus counties, CA Lisa Pasillas-Le, Health Net

More information

ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area

ROCHESTER 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 information

LOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY

LOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Calendar Year Out-of- Pocket Maximum Lifetime Maximum Per Individual Physician Office Visits Primary Care

More information

2016 Summary of Benefits

2016 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 information

University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance

University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.

More information

Medicare s Preventive Care Services. Manage Your Chronic Kidney Disease (CKD stages 3-4) with Diet

Medicare s Preventive Care Services. Manage Your Chronic Kidney Disease (CKD stages 3-4) with Diet s Preventive Care Services Manage Your Chronic Kidney Disease (CKD stages 3-4) with Diet What do the kidneys do? Your kidneys have important jobs to do in your body. Two of the kidneys most important jobs

More information

2015 Summary of Benefits

2015 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 information

HNE Premier 1 (HMO) and HNE Premier 2 (HMO)

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

More information

2015 Summary of Benefits

2015 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 information

January 1, 2015 December 31, 2015

January 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 information

NO DEDUCTIBLE FOR MANY SERVICES

NO DEDUCTIBLE FOR MANY SERVICES KAISER PERMANENTE FOR INDIVIDUALS AND FAMILIES Deductible Plans How Deductible plans work Deductible plans generally offer lower monthly premiums in exchange for higher out-of-pocket payments for covered

More information

Tribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP

Tribute. 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 information

Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only]

Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only] NCCT List of Procedures Treatment Category Inpatient Treatment Categories DRG (MS DRG) ICD9 [Hip & Knee Only] Bariatric Surgery - Laparoscopic Gastric Bypass DRG - 288 MS DRG - 621 Cardiac Angioplasty

More information

VISITING MEMBER SERVICES. Getting care away from home. For travel in other Kaiser Permanente areas

VISITING MEMBER SERVICES. Getting care away from home. For travel in other Kaiser Permanente areas 2016 VISITING MEMBER SERVICES Getting care away from home For travel in other Kaiser Permanente areas Getting care in Kaiser Permanente service areas This brochure will help you get a wide range of care

More information

FAIRBANKS NORTH STAR BOROUGH SCHOOL DISTRICT FAIRBANKS URGENT CARE PA CLINIC PROGRAM

FAIRBANKS NORTH STAR BOROUGH SCHOOL DISTRICT FAIRBANKS URGENT CARE PA CLINIC PROGRAM FAIRBANKS NORTH STAR BOROUGH SCHOOL DISTRICT FAIRBANKS URGENT CARE PA CLINIC PROGRAM The Fairbanks Urgent Care PA Clinic Program is a special health benefit program for School District employees and eligible

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits January 1, 2015 December 31, 2015 Kit 02 Y0067_PRE_H2816_SBK02_0814 CMS Accepted 09/13/2014 NPFFS-SB K02 2015 Section I Introduction to Summary of Benefits You have choices about

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

H9412_14238_8 File and Use 8/31/14

H9412_14238_8 File and Use 8/31/14 Introduction to Summary of s You have choices about how to get your Medicare benefits. One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare

More information

Independent Health s Medicare Passport Advantage (PPO)

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

More information

2015 Summary of Benefits

2015 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

FEATURES NETWORK OUT-OF-NETWORK

FEATURES NETWORK OUT-OF-NETWORK Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 3B Booklet Base: 3 For: Choice POS II - 950 Option - Retirees

More information

Summary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)

Summary 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 information

SUMMARY OF BENEFITS CARE1ST HEALTH PLAN. Care1st AdvantageOptimum Plan (HMO) California: Fresno, Merced, Stanislaus and San Joaquin Counties

SUMMARY OF BENEFITS CARE1ST HEALTH PLAN. Care1st AdvantageOptimum Plan (HMO) California: Fresno, Merced, Stanislaus and San Joaquin Counties SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 CARE1ST HEALTH PLAN 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 every

More information

Anthem Blue Cross Preferred Provider Organization (PPO)

Anthem Blue Cross Preferred Provider Organization (PPO) Anthem Blue Cross Preferred Provider Organization (PPO) 1-877-687-0549 Call Monday through Friday from 8:30 a.m. to 7:00 p.m. Plan Highlights Medical Services at Discounted Rates Anthem Blue Cross has

More information

99381, 99382: Initial preventive medicine evaluation 99391, 99392: Periodic preventive medicine re-evaluation

99381, 99382: Initial preventive medicine evaluation 99391, 99392: Periodic preventive medicine re-evaluation Age Birth - 24 months 2-11 s M/ M/ Preventive medicine, re-, or office visit/ 8 visits within the first 24 months of life (As part of preventive medicine or re-, Hemoglobin, hematocrit, or CBC for those

More information

NO DEDUCTIBLE FOR MANY SERVICES

NO DEDUCTIBLE FOR MANY SERVICES How Deductible plans work Deductible plans generally offer lower monthly premiums in exchange for higher out-of-pocket payments for covered services. With these plans, you pay full charge for certain covered

More information

Important Questions Answers Why this Matters:

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 Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

SUMMARY OF BENEFITS 2016 EmblemHealth PPO I and EmblemHealth Advantage (PPO) Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester

SUMMARY OF BENEFITS 2016 EmblemHealth PPO I and EmblemHealth Advantage (PPO) Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester SUMMARY OF BENEFITS 2016 and Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester January 1, 2016 December 31, 2016 H5528_125910 Accepted 9/13/2015 SECTION I - INTRODUCTION TO SUMMARY

More information

SCAN Health Plan. 2015 Summary of Benefits

SCAN Health Plan. 2015 Summary of Benefits SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8713_2014F File & Use Accepted 09032014 SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with

More information

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable

More information

Women with Medicare. Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam

Women with Medicare. Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam CENTERS FOR MEDICARE & MEDICAID SERVICES Women with Medicare Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam This official government booklet will help you understand what s

More information

School Board of Broward County

School Board of Broward County School Board of Broward County Open Enrollment 2013 Table of Contents Preventive Care Coverage...1 Knowing where to go can help you save on health care costs...2 Coventry WellBeing...3 WellBeing has its

More information

Preventive Services Explained

Preventive Services Explained Preventive Services Explained Medicare covers many preventive care services without charge. Most of these services have been recommended by the U.S. Preventive Services Task Force. However, which beneficiaries

More information

Colorado Small Business Enrollment Guide A BETTER WAY to take care of business

Colorado Small Business Enrollment Guide A BETTER WAY to take care of business 2015 SMALL BUSINESS HEALTH Colorado Small Business Enrollment Guide A BETTER WAY to take care of business Choose BETTER. 31 Important deadline Open enrollment begins on November 15, 2014 for coverage beginning

More information

Annually for adults ages 55 80 years with 30 pack/year smoking history and currently smoke or quit within the past 15 years Hepatitis B screening

Annually for adults ages 55 80 years with 30 pack/year smoking history and currently smoke or quit within the past 15 years Hepatitis B screening Preventive Care Schedule Effective January 1, 2016 Highmark Blue Cross Blue Shield Express Scripts The plan pays for preventive care only when given by a network provider. Certain vaccines are available

More information

CHOOSE A PLAN DEDUCTIBLE PLANS DEDUCTIBLE PLANS. What deductible plans offer and how they work IN THIS BROCHURE. n How our deductible plans work

CHOOSE A PLAN DEDUCTIBLE PLANS DEDUCTIBLE PLANS. What deductible plans offer and how they work IN THIS BROCHURE. n How our deductible plans work DEDUCTIBLE PLANS CHOOSE A PLAN DEDUCTIBLE PLANS What deductible plans offer and how they work IN THIS BROCHURE n How our deductible plans work n Understanding deductibles and out-of-pocket maximums n Benefit

More information

University of California Student Health Insurance Plan (UC SHIP) Student Health Center & Pharmacy (SHC) at UC Irvine (Graduate Students)

University of California Student Health Insurance Plan (UC SHIP) Student Health Center & Pharmacy (SHC) at UC Irvine (Graduate Students) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO)

CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO) Introduction to the Summary of Benefits Report for CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO) January 1, 2015 December 31, 2015 CAPITAL, CENTRAL, SOUTHERN TIER,

More information

Greater Tompkins County Municipal Health Insurance Consortium

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

More information

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING

Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD0000003378_ X Please Note: In this plan, Members have access to network benefits only from the providers in the Harvard Pilgrim-Lahey

More information

University of California Student Health Insurance Plan (UC SHIP) Arthur Ashe Student Health & Wellness Center (The Ashe Center)

University of California Student Health Insurance Plan (UC SHIP) Arthur Ashe Student Health & Wellness Center (The Ashe Center) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

2016 Summary of Benefits

2016 Summary of Benefits HMO and 2016 Summary of Benefits Western Pennsylvania H3957_15_0265 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay.

More information

SHIIP Combo Form. 1-855-408-1212 www.ncshiip.com. North Carolina Department of Insurance Wayne Goodwin, Commissioner

SHIIP Combo Form. 1-855-408-1212 www.ncshiip.com. North Carolina Department of Insurance Wayne Goodwin, Commissioner SHIIP Combo Form Seniors Health Insurance Information Program North Carolina Department of Insurance Wayne Goodwin, Commissioner 1-855-408-1212 www.ncshiip.com What is SHIIP? Seniors Health Insurance Information

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of

More information

LABORATORY and PATHOLOGY SERVICES

LABORATORY and PATHOLOGY SERVICES LABORATORY and PATHOLOGY SERVICES Policy Neighborhood Health Plan reimburses participating clinical laboratory and pathology providers for tests medically necessary for the diagnosis, treatment and prevention

More information

Understanding preventive care

Understanding preventive care Understanding preventive care We want you to be your healthiest. That s why the preventive services listed here are free for most members. What services are recommended? Know before you go. Preventive

More information

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health

More information

Summary 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 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

H3954_14238_3 File and Use 8/31/14

H3954_14238_3 File and Use 8/31/14 Introduction to Summary Of s You have choices about how to get your Medicare benefits. One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare

More information

Application for a Medical Impairment Rating (MIR)

Application for a Medical Impairment Rating (MIR) STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax

More information

IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)

IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services) HMO-OA-CNT-30-45-500-500D-13 HMO Open Access Contract Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations

More information

Including changes in health status since last exam. Known occupational exposures.

Including changes in health status since last exam. Known occupational exposures. Firefighters Medical Checklist Individualized Health Risk Appraisal Written feedback to uniformed personnel concerning health risks and health status is required following the annual examination. Reporting

More information

SERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE

SERVICES 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 information

SCAN Health Plan. 2015 Summary of Benefits

SCAN Health Plan. 2015 Summary of Benefits SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8712_2014F File & Use Accepted 09032014 ( a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with a Medicare contract)

More information

Your Guide to Medicare s Preventive Services

Your Guide to Medicare s Preventive Services Your Guide to Medicare s Preventive Services C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S This is the official government booklet with important information about: What disease

More information

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey

More information

Summary 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 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 information

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003) SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty

More information