Coventry Health & Life Insurance Company

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Coventry Health & Life Insurance Company"

Transcription

1 Coventry Health & Life Insurance Company (Benefits underwritten by Coventry Health & Life Insurance Company and Administered by Coventry Health Care of Missouri, Inc.) Small Group PPO Schedule of Benefits: Plan ID#: Bronze Q4800U (IL) (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain Covered Services. Refer to Your Certificate of Coverage (COC) for a detailed description of Covered Services and limitations or exclusions. To receive In-Network benefits, all Covered Services, except for Emergency Services, must be performed or referred by a Participating Provider with Coventry Health Care or Authorized in advance by the Plan. All services must be Medically Necessary as a condition of coverage and not otherwise limited or excluded. Certain services require Prior Authorization. Call the telephone number on the back of Your ID Card to Prior Authorize. Except for Emergency Services, charges by Non-Participating Providers in excess of the Out-of-Network Rate will not be Covered. Note that failure to Prior Authorize a service where Prior Authorization is required may result in the application of a penalty of the lesser of up to $1,000 or 50% of the billed charge. For in-patient hospitalizations, the penalty will be no more frequent than a per confinement basis. BENEFIT AND SERVICES 1 Annual Total amount a plan member is required to pay each benefit year before he or she is eligible for certain Covered Services. amounts accumulate separately for In- and Out-of- Network benefits. The family deductible is satisfied when all family members combine to meet the family deductible amounts. If you have individual coverage, you must satisfy the individual before any benefit will be paid. If you have family coverage, you must satisfy the family before any benefits will be paid for any member. Pharmacy Services are included in the. 2 Annual Out-of-Pocket Maximum Copayments, coinsurance, s and prescription drug costs all apply to the out-of-pocket maximum. Out-of-pocket amounts accumulate separately for In- and Out-of-Network benefits. The family out-of-pocket amount is satisfied when all family members combine to meet the family out-of-pocket maximum amounts. The following services do not apply to the out-of-pocket maximum: charges above the Out-of-Network Rate and penalties for failure to Prior Authorize services. Individual Individual $4,800 $9,000 Family Family $9,600 $18,000 Individual Individual $5,500 $18,000 Family Family $11,000 $36,000 3 Maximum Lifetime Benefit Combined total of all benefits. Unlimited Unlimited

2 BENEFIT AND SERVICES 4 Physician Office Visit - Preventive Care Services include routine health assessment, well-child care, immunizations and injections, routine hearing test, prostate specific antigen testing, annual self-referred gynecological examination and pap smear, and mammogram screening and other preventive care services mandated by the Affordable Care Act. Consult Your Certificate of Coverage for more information. For Primary Care Services For Primary Care Services $0 Copay per visit admission after No or Coinsurance for Immunizations to age 5 For Specialty Care For Specialty Care Services Services $0 Copay per visit admission after No or Coinsurance for Immunizations to age E-Visits - Medical Services 7 8 Physician Office Visit - Medical Services Services include diagnosis, consultation and treatment. Services include: - Adult immunizations - Vision examination - Surgery - Diagnostic lab work - Diagnostic radiology services - Injections - Allergy testing and treatment - Telemedicine Certain services require Prior Authorization. Convenience Care / Walk in Clinic (WIC) Covered Services received at a retail health clinic for the treatment of minor health concerns that do not constitute an Emergency or an Urgent Care. Chiropractic Services Services include treatment that is Medically Necessary, clinically appropriate and within the chiropractor's scope of practice up to 12 visits per benefit year. Maximum benefit is an In- and Out-of-Network combined limit without Prior Authorization. 9 Emergency Room Services Coverage is provided for worldwide emergency health services as defined in the Certificate of Coverage. Includes facility and professional charges. For Primary Care Services For Specialty Care Services For Primary Care Services For Specialty Care Services (Waived if patient is admitted) For Primary Care Services admission after For Specialty Care Services admission after For Primary Care Services admission after For Specialty Care Services admission after admission after admission after (Waived if patient is admitted)

3 BENEFIT AND SERVICES 10 Ambulance Services Coverage is provided for Emergency Services as defined in the COC. occurrence after occurrence after Urgent Care Services Covered Service for urgent care services provided at a true Urgent Care Facility as that term is defined under Illinois Emergency Medical Treatment Act both in and out of the Service Area. Maternity Care Office Visits Coverage for maternity care, including prenatal, delivery, and post-natal care. Maternity Care, Inpatient Hospital Covered Services include all physician/facility services for mother and newborn(s), newborn nursery services, and semiprivate room for a minimum of 48 hours (vaginal) and 96 (caesarian) following delivery. Also includes treatment of complications of pregnancy. Inpatient stays beyond 48 hours (vaginal) / 96 hours (caesarian) require Prior Authorization. 0% Coinsurance after admission after admission after admission after High Technology Diagnostic Services, Tests, and Procedures Including, but not limited to: MRI, MRA, CT Scans, Thallium Scans, Nuclear Stress Tests, PET Scans, Echocardiograms (regardless of where service is performed). Requires Prior Authorization Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to lab and radiology, not performed in the physician's office. Certain procedures and tests may be considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section of Your COC for more information. Certain services require Prior Authorization. Outpatient Surgery Benefits are provided for Covered Services rendered at an outpatient hospital for free standing surgery center. Requires Prior Authorization. Injectable Medications Requires Prior Authorization. admission after admission after admission after admission after Covered according to the type of benefit incurred and the place where the service is received. Covered according to the type of benefit incurred and the place where the service is received.

4 BENEFIT AND SERVICES 18 Inpatient Hospital Services Coverage is provided for Medically Necessary Physician and surgeon services, semi-private room, operating room and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, short-term rehabilitation services, nursing care, meals and special diets. Inpatient alcoholism treatment is Covered the same as any other sickness. Requires Prior Authorization. 19 Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission when Prior Authorized. Coverage is provided for a semiprivate room. 20 Home Health Care and Hospice Coverage is provided for home health care and/or home infusion therapy services provided in Your home when Prior Authorized. admission after admission after admission after admission after admission after 21 Private Duty Nursing 22 Hospice Covered for hospice services provided in Your home when Prior Authorized. 23 Durable Medical Equipment Coverage is provided when services are Prior Authorized for equipment purchased in excess of $500 and for all rental equipment. 24 Prosthetics and Customized Orthotic Devices State mandated coverage is for prosthetic and custom-made orthotic devices (except foot orthotics) under terms and conditions no less favorable than that applied to substantially all medical and surgical benefits provided under the plan. Requires Prior Authorization for prosthetic devices purchased in excess of $ Eyeglasses and Contacts Coverage is provided for the first pair of eyeglasses or corrective lenses following cataract surgery. 0% Coinsurance of covered expenses after 0% Coinsurance of covered expenses after 100% of Covered Eyewear after admission after admission after 30% Coinsurance of covered expenses after 30% Coinsurance of covered expenses after admission after

5 BENEFIT AND SERVICES 26 Outpatient Physical, Occupation and Speech Therapy Coverage is provided for Medically Necessary outpatient physical, occupational and speech therapy. Includes coverage for Medically Necessary habilitative services for persons who have a congenital, genetic or early acquired disorder, preventive physical therapy for insureds diagnosed with multiple sclerosis and speech therapy for PDD. Physical Therapy in a custodial setting requires prior authorization. admission after Inpatient Rehabilitation Therapy Services Includes short-term inpatient rehabilitation services. Mental Health/Substance Use Disorder - Inpatient All inpatient mental health and Substance use disorder services, except emergency admissions, must be Prior Authorized by calling the Coventry Health Care behavior health line toll free at the number on the back of Your ID Card. admission after admission after admission after admission after Diagnosis, detoxification, and treatment of medical complications of alcoholism is covered the same as any other illness. Coverage includes inpatient treatment for mental health and Substance use in a: - Hospital or psychiatric hospital - Residential treatment facility - Partial Hospitalization treatment program - Detoxification program

6 29 Mental Health/Substance Use Disorder - Outpatient Hospital Coverage includes outpatient mental health and Substance use disorder services in an: - Outpatient Hospital or psychiatric hospital - Intensive Outpatient Program (IOP) - Residential treatment facility 30 BENEFIT AND SERVICES Mental Health/Substance Use Disorder - Office Visits Includes outpatient mental health and substance use disorder services performed in an office setting. Diagnosis, detoxification, and treatment of medical complications of alcoholism is covered the same as any other illness. admission after admission after 31 Transplant Services Services and supplies for transplants are Covered when Participating Coventry Transplant Network Providers are utilized. Requires Prior Authorization. 32 Modified Foods (PKU/Metabolic Formula) 33 Temporomandibular Joint Disorder admission after Not Covered admission after 34 Bariatric Surgery Requires prior authorization. admission after 35 Family Planning Coverage includes diagnosis and treatment of infertility, including coverage for IVF, GIFT, and ZIFT. All services require Prior Authorization. admission after

7 36 Well Baby/Child Exams Coverage is limited to: Covered Persons through age BENEFIT AND SERVICES Limited to 7 exams in the first 12 months Limited to 3 exams in the second 12 months Limited to 3 exams in the third 12 months Limited to 1 exam thereafter per benefit period Screening and Counseling Office Visits: Obesity and healthy diet counseling Misuse of alcohol and/or drugs Use of tobacco products Sexually transmitted infection counseling Genetic risk counseling for breast and ovarian cancer Maximums: Obesity and Healthy Diet Counseling: Maximum Visits per benefit period: 26 visits (however, of these only 10 visits will be allowed under the These maximums applies only to Covered Persons ages 22 & older. Misuse of Alcohol and/or Drugs: Maximum Visits per benefit period: 5 visits* Use of Tobacco Products: Maximum Visits per benefit period: 8 visits* Sexually Transmitted Infection Counseling: Maximum visits per benefit period: 2 visits* Genetic Risk Counseling for Breast and Ovarian Cancer: Not subject to any age or frequency limitations Lactation Counseling Services : Maximum Visits per benefit period either in a group or individual setting: 6 visits* Note: Applicable PCP or Specialist cost-share will apply for visits in excess of the Lactation Counseling Services Maximum. Breast Feeding Durable Medical Equipment Maximum: Breast pumps and supplies are limited to 1 electric breast pump per 36 months Female Contraceptive Counseling Services: Maximum Visits per benefit year either in a group or individual setting: 2 visits* Note: Applicable PCP or Specialist cost-share will apply for visits in excess of the Female Contraceptive Counseling Services Maximum Lung cancer screenings are limited to 1 screening per Calendar Year. Additional visits are subject to PCP or Specialist cost share. For Primary Care Services For Primary Care Services $0 per visit admission after No or Coinsurance for Immunizations to age 5 For Primary Care Services For Primary Care Services $0 per visit admission after For Specialty Care Services $0 per visit No or Coinsurance for Immunizations to age 5 For Specialty Care Services For Specialty Care Services $0 per visit admission after For Specialty Care Services admission after

8 BENEFIT AND SERVICES 38 Hearing Aids (Children over 5 Years of age) hearing aid after admission after **YOU ARE RESPONSIBLE FOR AMOUNTS IN EXCESS OF THE OUT OF NETWORK RATE IN ADDITION TO APPLICABLE COPAYMENT, COINSURANCE AND DEDUCTIBLES.

9 PRESCRIPTION DRUG BENEFITS Important Note: '- If you or your prescriber request a covered brand-name Prescription Drug when a covered generic Prescription Drug equivalent is available, you will be responsible for the cost difference between the generic Prescription Drug and the brand name Prescription Drug, plus the applicable cost sharing. PLAN FEATURES Prescription Drug Individual: Family: Not Applicable Not Applicable Important Reminder: -The benefit year s that apply to medical benefits under this plan are found earlier in this Schedule of Benefits under the Annual section on page 1. - All Prescription Drug Covered Benefits Are Subject To The Annual Unless Noted in the Schedule of Benefits Below. Not Applicable Not Applicable PHARMACY BENEFIT PER PRESCRIPTION COPAYMENTS/COINSURANCE Prescription Drug - Retail: For each 31 day supply filled at a retail pharmacy. Tier 1: Preferred Generic Drugs Retail: Mail Order: Retail: Mail Order: Prescription Drug - Mail Order: For each 90 day supply filled at a mail order pharmacy. Tier 1A: Value Drugs $3 Copay after $6 Copay after $10 Copay after $20 Copay after Tier 2: Preferred Brand Drugs Tier 3: Non-Preferred Brand/Generic Drugs Retail: Mail Order: Retail: $30 Copay after $75 Copay after $75 Copay after Mail Order: $225 Copay after Tier 4: Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 30% Coinsurance up to $250 maximum per prescription after Tier 5: Non-Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 50% Coinsurance up to $500 maximum per prescription after

10 Pediatric Vision Benefit Vision Care Services * * Covered only through the EyeMed Network Exam with Dilation as Necessary Vision Screening for Children under 19 One routine eye examination per calendar year Vision Hardware Eye Glasses for Children under 19 One pair of standard eyeglass lenses or contact lenses per year; one frame every calendar year Contact Lens Fit and Follow-Up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed.) Standard Contact Lens Fit and Follow-Up: Premium Contact Lens Fit and Follow-Up: Frames: Designated available frame at provider location Standard Lenses (Glass or Plastic): Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Lens Options: UV Treatment Tint (Fashion & Gradient & Glass-Grey) Standard Plastic Scratch Coating Standard Polycarbonate - Kids under 19 Contact Lenses: (Contact lens includes materials only) Extended Wear Disposables - Up to 6 month supply of monthly or 2 week disposable, single vision spherical or toric contact lenses. Daily Wear / Disposables - Up to 3 month supply of daily disposable, single vision spherical contact lenses Medically Necessary / Conventional: Low Vision Evaluation, low vision aides, follow up care once every calendar year (includes examination, lenses or contact lenses, frame); once every 5 years includes comprehensive low vision evaluation; Follow up care for low vision services - 4 visits in a 5 year period. In-Network EyeMed Network Member Cost $0 Copay $0 Copay after $0 Copay after 100% coverage for provider designated frames $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after 100% coverage for provider designated contact lenses after Paid in Full 5

11 Pediatric Dental Care Benefit Schedule of Benefits Pediatric Dental Care Description of Covered Services Type In-Network Out-of-Network PREVENTIVE & DIAGNOSTIC Routine Exams/Evaluations (Limited to 1 per 6 months) I $0 Copay $0 Copay Cleanings (Limited to 1 per 6 months) I $0 Copay $0 Copay X-rays I $0 Copay $0 Copay Fluoride (One per year) I $0 Copay $0 Copay Sealants I $0 Copay $0 Copay BASIC Space Maintainer Fillings Denture Relines General Anesthesia, IV Sedation, Conscious Sedation, Therapeutic Drug Injection, Nitrous Oxide (Requires pre-determination) II II II II General Services II MAJOR Crowns Requires pre-determination Removable Prostodontic Services: Dentures (Complete: Upper and Lower; Partial: Upper and Lower) Requires pre-determination Fixed Prosthetic Services - Bridges Requires pre-determination Endodontics Periodontics (Gingevectomy, Scaling and Root Planing) Requires pre-determination Oral Surgery (Extractions, Surgical Extractions, Alveoplasty) (Surgical Extractions and Alveoplasty require pre-determination) ORTHODONTIA Covered only in cases of medical necessity and subject to pre-determination. Out-of-Pocket Maximum III III III III III III IV & Out-of-Pocket Maximum combined with medical

12 Note that Prior Authorization may be required for some services. * Coverage: The amount of reimbursement by Us for pediatric dental services Covered under this Rider will depend upon whether You receive those services from Participating or Non-Participating Dental Providers. Participating Dental Providers are those licensed dentists who have a contract with Us and have agreed to accept a discounted rate as payment in full for those services. You will receive the highest level of coverage if you receive Covered Services from Participating Dental Providers. If You receive Covered pediatric dental services from Non-Participating Dental Providers, Our reimbursement for those services will be limited and based upon the Out-of-Network Rate for the service, which is a rate established by Us based upon our contracted rate with Participating Providers in our dental network. We will pay the enumerated percentage of that Out-of-Network Rate as and for our reimbursement to the Non-Participating Dental Provider, and You will be responsible for any amount over and above the Out-of-Network Rate in addition to other applicable member responsibility, such as or Coinsurance

Coventry Health Care of Missouri

Coventry Health Care of Missouri Small Group PPO Schedule of Benefits: Coventry Health Care of Missouri Plan ID#: Platinum Carelink from Coventry A000-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain

More information

Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits:

Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits: Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits: Plan ID#: Silver Traditional 3000 90-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain

More information

MyHPN Solutions HMO Silver 4

MyHPN Solutions HMO Silver 4 MyHPN Solutions HMO Silver 4 Attachment A Schedule Calendar Year Deductible (CYD): $2,250 of EME per Member and $4,500 of EME per family. The Calendar Year Out of Pocket Maximum includes the CYD and is

More information

Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016

Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to

More information

PLAN DESIGN AND BENEFITS POS Open Access Plan 1944

PLAN DESIGN AND BENEFITS POS Open Access Plan 1944 PLAN FEATURES PARTICIPATING Deductible (per calendar year) $3,000 Individual $9,000 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being

More information

Summary of Services and Cost Shares

Summary of Services and Cost Shares Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

More information

DRAKE UNIVERSITY HEALTH PLAN

DRAKE UNIVERSITY HEALTH PLAN DRAKE UNIVERSITY HEALTH PLAN Effective Date: 1/1/2015 This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and the conditions specified in the

More information

National PPO 1000. PPO Schedule of Payments (Maryland Small Group)

National 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 information

AVMED 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. 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 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

Benefits At A Glance Plan C

Benefits At A Glance Plan C Benefits At A Glance Plan C HIGHLIGHTS OF WELFARE FUND BENEFITS WELFARE FUND BENEFITS IN BRIEF Medical and Hospital Benefits Empire BlueCross BlueShield Plan C-1 Empire BlueCross BlueShield Plan C-2 All

More information

2015 Medical Plan Summary

2015 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 information

Health Choice Essential Gold Standard Gold Off Exchange Plan Network: Health Choice Essential Type of Coverage: HMO

Health Choice Essential Gold Standard Gold Off Exchange Plan Network: Health Choice Essential Type of Coverage: HMO Subscriber ID: [XXXXXXX] Health Choice Essential Gold Standard Gold Off Exchange Plan Network: Health Choice Essential Type of Coverage: HMO EOC Effective Date: [XX/XX/XXXX] Subscriber: [Subscriber Name]

More information

PPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20

PPO 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 information

Coventry HealthAmerica Small Business Solutions PENNSYLVANIA

Coventry HealthAmerica Small Business Solutions PENNSYLVANIA Coventry HealthAmerica Small Business Solutions PENNSYLVANIA Plan Name Coinsurance Single 2x Family PCP Office Visit Specialist Office Visit Convenience Care Urgent Care Emergency Room Labs X-ray Diagnostics

More information

Blue Cross Premier Bronze Extra

Blue 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 information

PLAN DESIGN AND BENEFITS HMO Open Access Plan 912

PLAN DESIGN AND BENEFITS HMO Open Access Plan 912 PLAN FEATURES Deductible (per calendar year) $1,000 Individual $2,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services

More information

SMALL GROUP PLAN DESIGN AND BENEFITS OPEN CHOICE OUT-OF-STATE PPO PLAN - $1,000

SMALL GROUP PLAN DESIGN AND BENEFITS OPEN CHOICE OUT-OF-STATE PPO PLAN - $1,000 PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year; applies to all covered services) $1,000 Individual $3,000 Family $2,000 Individual $6,000 Family Plan Coinsurance ** 80% 60%

More information

Ultimate Full PPO for Small Business 0 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix)

Ultimate Full PPO for Small Business 0 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Ultimate Full PPO for Small Business 0 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED

More information

PLAN DESIGN AND BENEFITS AETNA LIFE INSURANCE COMPANY - Insured

PLAN DESIGN AND BENEFITS AETNA LIFE INSURANCE COMPANY - Insured PLAN FEATURES Deductible (per calendar year) Individual $750 Individual $1,500 Family $2,250 Family $4,500 All covered expenses accumulate simultaneously toward both the preferred and non-preferred Deductible.

More information

$6,350 Individual $12,700 Individual

$6,350 Individual $12,700 Individual PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $5,000 Individual $10,000 Individual $10,000 Family $20,000 Family All covered expenses accumulate separately toward the preferred or non-preferred Deductible.

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

California Small Group MC Aetna Life Insurance Company

California Small Group MC Aetna Life Insurance Company PLAN FEATURES Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate separately

More information

What is the overall deductible? Are there other deductibles for specific services?

What 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 information

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

Prescription Drugs and Vision Benefits

Prescription Drugs and Vision Benefits Medical Plans Prescription Drugs and Vision Benefits Salaried Employees. may enroll for coverage in either the Cigna Open Access Plus Plan or the Cigna Choice Fund (Health Savings Account [HSA] Eligible)

More information

PLAN DESIGN AND BENEFITS - PA Health Network Option AHF HRA 1.3. Fund Pays Member Responsibility

PLAN DESIGN AND BENEFITS - PA Health Network Option AHF HRA 1.3. Fund Pays Member Responsibility HEALTHFUND PLAN FEATURES HealthFund Amount (Per plan year. Fund changes between tiers requires a life status change qualifying event.) Fund Coinsurance (Percentage at which the Fund will reimburse) Fund

More information

Anthem BCBS PPO 80/60. Network Out-of-Network Network Out-of-Network Network Out-of-Network $1,750 per person. $2,500 per person $5,000 per family

Anthem BCBS PPO 80/60. Network Out-of-Network Network Out-of-Network Network Out-of-Network $1,750 per person. $2,500 per person $5,000 per family Plan PPO 90/70 PPO 80/60 PPO 75/50 Annual Medical Deductible Network Out-of-Network Network Out-of-Network Network Out-of-Network $250 per person $500 per person $500 per person $1,000 per person $900

More information

Additional Information Provided by Aetna Life Insurance Company

Additional Information Provided by Aetna Life Insurance Company Additional Information Provided by Aetna Life Insurance Company Inquiry Procedure The plan of benefits described in the Booklet-Certificate is underwritten by: Aetna Life Insurance Company (Aetna) 151

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

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

Medical Plan - Healthfund

Medical Plan - Healthfund 18 Medical Plan - Healthfund Oklahoma City Community College Effective Date: 07-01-2010 Aetna HealthFund Open Choice (PPO) - Oklahoma PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY -

More information

California Small Group MC Aetna Life Insurance Company

California Small Group MC Aetna Life Insurance Company PLAN FEATURES Deductible (per calendar year) $1,000 per member $1,000 per member Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate

More information

Sherwin-Williams Medical, Prescription Drug and Dental Plans Plan Comparison Charts

Sherwin-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 information

HDHP/HSA. $3,000 per person $6,000 per family (deductible includes medical & prescriptions) $7,000 per person $13,000 per family

HDHP/HSA. $3,000 per person $6,000 per family (deductible includes medical & prescriptions) $7,000 per person $13,000 per family Plan Aetna Select EPO BCBS PPO 90/70 BCBS HDHP/HSA High Option EPO EPO 80 Choice Choice Plus 80/60 Annual Medical Deductible Annual Out-of-Pocket Maximum (includes deductible) Network Only Network Out-of-Network

More information

Final. $2,500 per member $5,000 per family

Final. $2,500 per member $5,000 per family Final PPO PPO Medical, Rx, Dental Core, Dental Buy Up Benefits-at-a-Glance City of Pontiac Group Number: 71489 Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Copays/Coinsurance

More information

PLAN DESIGN AND BENEFITS Georgia 2-100 HNOption 13-1000-80

PLAN DESIGN AND BENEFITS Georgia 2-100 HNOption 13-1000-80 Georgia Health Network Option (POS Open Access) PLAN DESIGN AND BENEFITS Georgia 2-100 HNOption 13-1000-80 PLAN FEATURES PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS Deductible (per calendar year)

More information

Coventry Health and Life Insurance Company PPO Schedule of Benefits

Coventry 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 information

PLAN DESIGN AND BENEFITS Basic HMO Copay Plan 1-10

PLAN DESIGN AND BENEFITS Basic HMO Copay Plan 1-10 PLAN FEATURES Deductible (per calendar year) Member Coinsurance Not Applicable Not Applicable Out-of-Pocket Maximum $5,000 Individual (per calendar year) $10,000 Family Once the Family Out-of-Pocket Maximum

More information

BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company

BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company Appendix A BENEFIT PLAN Prepared Exclusively for The Dow Chemical Company What Your Plan Covers and How Benefits are Paid Choice POS II (MAP Plus Option 2 - High Deductible Health Plan (HDHP) with Prescription

More information

California PCP Selected* Not Applicable

California PCP Selected* Not Applicable PLAN FEATURES Deductible (per calendar ) Member Coinsurance * Not Applicable ** Not Applicable Copay Maximum (per calendar ) $3,000 per Individual $6,000 per Family All member copays accumulate toward

More information

Bates College Effective date: 01-01-2010 HMO - Maine PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC. - FULL RISK PLAN FEATURES

Bates College Effective date: 01-01-2010 HMO - Maine PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC. - FULL RISK PLAN FEATURES PLAN FEATURES Deductible (per calendar year) $500 Individual $1,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family

More information

PLAN DESIGN AND BENEFITS - Tx OAMC Basic 2500-10 PREFERRED CARE

PLAN DESIGN AND BENEFITS - Tx OAMC Basic 2500-10 PREFERRED CARE PLAN FEATURES Deductible (per calendar year) $2,500 Individual $4,000 Individual $7,500 Family $12,000 Family 3 Individuals per Family 3 Individuals per Family Unless otherwise indicated, the Deductible

More information

COMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES

COMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES COMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES Effective July 1, 2016 Medical/Vision/Pharmacy coverage is administered by PacificSource Health Plans Dental coverage is administered

More information

Optional PREFERRED CARE. Covered 100%; deductible waived

Optional PREFERRED CARE. Covered 100%; deductible waived PLAN FEATURES Deductible (per plan year) $2,000 Employee $2,000 Employee $3,000 Employee + Spouse $3,000 Employee + Spouse $3,000 Employee + Child(ren) $3,000 Employee + Child(ren) $4,000 Family $4,000

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

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

PREFERRED CARE. All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Payment Limit.

PREFERRED CARE. All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Payment Limit. PLAN FEATURES Deductible (per plan year) $300 Individual $300 Individual None Family None Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non-preferred

More information

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ 398.34] Two-Person [$796.68] Family Coverage [$1,210.66]] Benefit

More information

SCHEDULE OF BENEFITS

SCHEDULE OF BENEFITS SCHEDULE OF BENEFITS Premier HealthOne Bronze 5500 Health Maintenance Organization (HMO) Individual Certificate of Coverage This schedule of benefits (SOB) is part of your Certificate of Coverage (COC)

More information

International Student Health Insurance Program (ISHIP) 2014-2015

International Student Health Insurance Program (ISHIP) 2014-2015 2014 2015 Medical Plan Summary for International Students Translation Services If you need an interpreter to help with oral translation services, you may contact the LifeWise Customer Service team at 1-800-971-1491

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective General Services In-Network Out-of-Network Physician office visit Urgent care

More information

100% Fund Administration

100% Fund Administration FUND FEATURES HealthFund Amount $500 Employee $750 Employee + Spouse $750 Employee + Child(ren) $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance Percentage at which the Fund

More information

Important Questions Answers Why this Matters: Referred providers $0 person/ $0 family; self-referred providers $2,500 person/ $5,000 family

Important Questions Answers Why this Matters: Referred providers $0 person/ $0 family; self-referred providers $2,500 person/ $5,000 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.thehealthplan.com or by calling 1-800-447-4000. Important

More information

New York Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010. PLAN DESIGN AND BENEFITS - NY Indemnity 1-10/10*

New York Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010. PLAN DESIGN AND BENEFITS - NY Indemnity 1-10/10* PLAN FEATURES Deductible (per calendar year) $2,500 Individual $7,500 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,

More information

Benefits at a Glance: Visa Inc. Policy Number: 00784A

Benefits at a Glance: Visa Inc. Policy Number: 00784A Benefits at a Glance: Visa Inc. Policy Number: 00784A Visa Inc. Benefits at a Glance Policy #00784A Effective Date: January 1, 2016 Visa Inc. offers Medical, Pharmacy, Vision, Dental and Medical Evacuation

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

Employee + 2 Dependents

Employee + 2 Dependents FUND FEATURES HealthFund Amount $500 Individual $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance Percentage at

More information

SUMMARY OF BENEFITS. Out-of-Network Care: $10,000 per policy year

SUMMARY OF BENEFITS. Out-of-Network Care: $10,000 per policy year OUTPATIENT BENEFITS Most Primary Care office visits at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the

More information

SUMMARY!OF!BENEFITS!

SUMMARY!OF!BENEFITS! SUMMARY!OF!BENEFITS!! BASIC!PLAN! COMPREHENSIVE! Policy Year Maximum Unlimited Unlimited Out-of-Pocket Limit OUTPATIENT!BENEFITS! Doctor s Visits Most Primary Care office visits at SHC are provided at

More information

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan

Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined

More information

PLAN DESIGN AND BENEFITS - Tx OAMC 1500-10 PREFERRED CARE

PLAN DESIGN AND BENEFITS - Tx OAMC 1500-10 PREFERRED CARE PLAN FEATURES Deductible (per calendar year) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family 3 Individuals per Family 3 Individuals per Family Unless otherwise indicated, the Deductible

More information

IL Small Group PPO Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- PPO HSA HDHP $2,500 100/80 (04/09)

IL Small Group PPO Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- PPO HSA HDHP $2,500 100/80 (04/09) PLAN FEATURES OUT-OF- Deductible (per calendar ) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.

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 policy or plan document at www.thehealthplan.com or by calling 1-800-447-4000. Important

More information

Benefit Highlights for UNC Greensboro students

Benefit Highlights for UNC Greensboro students bcbsnc.com/uncg Benefit Highlights for UNC Greensboro students Effective 08/01/2016 StdGrp, 4/16 U9096a, 5/16 Table of Contents This brochure is a general summary of the insurance plan offered by Blue

More information

1 exam every 12 months for members age 22 to age 65; 1 exam every 12 months for adults age 65 and older. Routine Well Child

1 exam every 12 months for members age 22 to age 65; 1 exam every 12 months for adults age 65 and older. Routine Well Child PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,000 Individual $1,000 Individual $2,000 Family $2,000 Family All covered expenses accumulate separately toward the preferred or

More information

Cost Sharing Definitions

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 information

PDS Tech, Inc Proposed Effective Date: 01-01-2012 Aetna HealthFund Aetna Choice POS ll - ASC

PDS Tech, Inc Proposed Effective Date: 01-01-2012 Aetna HealthFund Aetna Choice POS ll - ASC FUND FEATURES HealthFund Amount $500 Individual $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance 100% Percentage

More information

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests) A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual

More information

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services

please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY PPO PLAN MAINE ID: MD0000000750_F2 X This Schedule of s summarizes your benefits under The HPHC Insurance Company PPO Plan (the Plan)

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective General Services In-Network Out-of-Network Primary care physician You pay $25 copay per visit Physician office

More information

SCHEDULE OF BENEFITS (continued) Group LINK Comprehensive Health Insurance Policy

SCHEDULE OF BENEFITS (continued) Group LINK Comprehensive Health Insurance Policy SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ 398.34] Two-Person [$796.68 ] Family Coverage [$1,210.66]] Benefit

More information

PLAN DESIGN AND BENEFITS - New York Open Access EPO 1-10/10

PLAN DESIGN AND BENEFITS - New York Open Access EPO 1-10/10 PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,

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

THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA)

THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA) THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA) Effective Date: 01-01-2016 PLAN FEATURES Annual Deductible $1,500 Employee $3,000 Employee $3,000 Employee + 1 Dependent

More information

2015 Medical Plan Options Comparison of Benefit Coverages

2015 Medical Plan Options Comparison of Benefit Coverages Member services 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-800-464-4000 Web site www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/

More information

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE

Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE ID: MD0000003228_B3 X Schedule of s Harvard Pilgrim Health Care of New England, Inc. THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO - LP NEW HAMPSHIRE Coverage under this Plan is under the jurisdiction

More information

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ 398.34] Two-Person [$796.68] Family Coverage [$1,210.66]] Benefit

More information

SCHEDULE OF BENEFITS. Group LINK Comprehensive Health Insurance Policy

SCHEDULE OF BENEFITS. Group LINK Comprehensive Health Insurance Policy SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ 398.34] Two-Person [$796.68] Family Coverage [$1,210.66]] Benefit

More information

Group Insurance Plan of Benefits for New York University (Control # 620610) administered by Aetna International Effective Date: January 1, 2016

Group Insurance Plan of Benefits for New York University (Control # 620610) administered by Aetna International Effective Date: January 1, 2016 Eligibility Provision Employee Regular full-time employees of New York University participating in this plan working a minimum of 25 hours per week. Dependent Wife or husband; same or opposite sex domestic

More information

PLAN DESIGN AND BENEFITS - Tx OAMC 2500 08 PREFERRED CARE

PLAN DESIGN AND BENEFITS - Tx OAMC 2500 08 PREFERRED CARE PLAN FEATURES Deductible (per calendar year) $2,500 Individual $5,000 Individual $7,500 3 Individuals per $15,000 3 Individuals per Unless otherwise indicated, the Deductible must be met prior to benefits

More information

Western Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/2016-12/31/2016

Western 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 information

CA Group Business 2-50 Employees

CA Group Business 2-50 Employees PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Member Coinsurance Copay Maximum (per calendar year) Lifetime Maximum Referral Requirement PHYSICIAN SERVICES Primary

More information

What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket

What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket Regence BlueShield: Regence Direct Gold with Dental, Vision, Individual Assistance Program Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What

More information

Healthy Benefits PPO 6000.0 - Zero Cost Sharing Plan Variation Coverage Period: Beginning on or after 1/1/2014 Summary of Benefits and Coverage:

Healthy Benefits PPO 6000.0 - Zero Cost Sharing Plan Variation Coverage Period: Beginning on or after 1/1/2014 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 capbluecross.com or by calling 1-800-730-7219. Important

More information

PLAN DESIGN & BENEFITS - CONCENTRIC MODEL

PLAN DESIGN & BENEFITS - CONCENTRIC MODEL PLAN FEATURES Deductible (per calendar year) Rice University None Family Member Coinsurance Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $1,500 Individual $3,000 Family

More information

PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)

PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year) Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists

More information

Health Insurance Benefits Summary

Health Insurance Benefits Summary Independent licensee of the Blue Cross and Blue Shield Association Health Insurance Benefits Summary Community Blue SM PPO Health Maintenance Exam (1) Covered 100%, one per calendar year, includes select

More information

Outline of Coverage SmartHealth Balance Gold 1000

Outline of Coverage SmartHealth Balance Gold 1000 Outline of Coverage SmartHealth Balance Gold 1000 This outline of coverage provides a very brief description of the important features of the policy. Please note this outline is not intended to be part

More information

Coverage for: Large Group Plan Type: HMO

Coverage 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 information

California Ironworkers Field Welfare Plan 1/1/2014 Open Enrollment Benefit Plan Comparison Non-Medicare Retired Participants Residing in Nevada

California Ironworkers Field Welfare Plan 1/1/2014 Open Enrollment Benefit Plan Comparison Non-Medicare Retired Participants Residing in Nevada Non- Choice of Providers Calendar Year Deductible *The Fund s Calendar Year Deductible is never waived. However, some services are not subject to the Deductible. If you live in Nevada, your network of

More information

HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC.

HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC. 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

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

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Gold 80 PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:

More information

Unlimited except where otherwise indicated.

Unlimited except where otherwise indicated. PLAN FEATURES Deductible (per calendar year) $1,250 Individual $5,000 Individual $2,500 Family $10,000 Family All covered expenses including prescription drugs accumulate separately toward both the preferred

More information

Land of Lincoln Health : Family Health Network LLH 3-Tier Bronze PPO Coverage Period: 01/01/2016 12/31/2016

Land 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 information

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy

SCHEDULE OF BENEFITS. Group Access Care Comprehensive Health Insurance Policy SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ 398.34] Two-Person [$796.68] Family Coverage [$1,210.66]] Benefit

More information

Important Questions Answers Why this Matters:

Important 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 information

FCPS BENEFITS COMPARISON Active Employees and Retirees Under 65

FCPS BENEFITS COMPARISON Active Employees and Retirees Under 65 FCPS S COMPARISON Medical Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Individual Annual Deductible None $250 None $250 None Family Annual Deductible Limit None $500 None $500 None

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? : VIVA HEALTH Access 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

More information