STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON EFFECTIVE JANUARY 1, 2016

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON EFFECTIVE JANUARY 1, 2016"

Transcription

1 This comparison is only a summary of benefits. Benefits will be administered as described in each plan s Summary of Benefits & Coverage. For further details, refer to those documents or call Wellmark Blue Cross Blue Shield at If there are discrepancies between this summary and Wellmark s benefit certificates, the certificates will govern in all cases. General Conditions of Coverage Benefits Available from Non- Participating Providers You are responsible for any amounts between the billed charge and the maximum allowable fee paid by Wellmark. These amounts will not accumulate towards the medical out-of pocket maximum. None, unless prescribed and referred by a participating physician and approved by Wellmark, or in an emergency medical situation. Normal plan benefits for network providers. Normal plan benefits for nonnetwork providers. Normal plan benefits. Coinsurance Percentage Not applicable unless noted below. 10% 20% 20% for all services Deductible None Single: $250 Single: $250 Single: $300 Family deductible is reached Family: $500 Family: $500 Family: $400 from amounts accumulated on behalf of any family member or Applies to both inpatient and Inpatient services only. combination of family members. outpatient services. Applies to both inpatient and outpatient services. Waived for services provided in office/clinic setting of select provider. The entire family deductible must be met before benefits payments are made. Dependent Child Age Limit Children through the end of the year in which they turn age 26 regardless of marital status or residency. Unmarried children over the age of 26 who are full-time students in an accredited institution of post secondary education. Unmarried children who are totally and permanently disabled, physically or mentally, regardless of age. The disability must have existed before the child turned age 27 or while a full-time student. Medical Maximum Out-of- Pocket (MOP) Family maximum out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single: $750 Family: $1500 All copayments and coinsurance go toward out-of-pocket limit. Single: $650 Family: $1,450 Applies to services provided both in- and out-of-network. All deductibles, coinsurance, and copayments go toward out-ofpocket limit. Emergency Room copayment continues to apply after out-of-pocket limit is met. Single: $650 Family: $1,450 Applies to services provided both in- and out-of-network. All deductibles, coinsurance, and copayments go toward out-ofpocket limit. Emergency Room copayment continues to apply after out-of-pocket limit is met. Single: $650 Family: $1,450 All deductibles, coinsurance, and copayments go toward out-of-pocket limit. Lifetime Benefit Maximum None None None New Employee Preexisting No preexisting conditions No preexisting conditions No preexisting conditions Condition Waiting Period Revised 03/2016 Page 1

2 Monthly Premiums Single Coverage Note: Rates shown are 1/12 the annual cost $ $ $ Family Coverage 2 State Employees Coverage $1, $ $1, $ $1, Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ UNI Employees Coverage $1, Professional Office Services $1, $1, Office Visit $10 copayment Allergy Testing $10 copayment 10%, deductible waived 20%, after deductible 20%, no deductible Allergy Serum and Injections $10 copayment 10%, deductible waived 20%, after deductible 20%, no deductible Chiropractor $10 copayment, if approved 10%, deductible waived 20%, after deductible 20%, no deductible Routine Eye Exam $10 copayment Not covered Routine Hearing Exam Maternity Surgery, Radiology & Pathology (Office) *Limit of one exam per member per calendar year $10 copayment *Limit of one exam per member per calendar year 0% for delivery. $10 copayment for initial visit; remaining pre and postnatal visits paid in full *Limit one exam per member per year. *Limit one exam per member per year. 10%, deductible waived in office setting for pre and post-natal visits *Limit of one exam per member per calendar year Not covered *Limit of one exam per member per calendar year 20% after deductible 20%, no deductible for pre and post-natal office visits. $10 10%, deductible waived 20%, after deductible 20%, no deductible Revised 03/2016 Page 2

3 Hospital Services Inpatient Hospital Services Preapproval of Inpatient Admission Inpatient Hospital Services Room & Board Inpatient Physician Services Inpatient Supplies Inpatient Surgery Outpatient Hospital Services STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON Required Required Required Required 10% 10%, after deductible 20%, after deductible 20%, after deductible Ambulatory Surgical Center 10% 10%, after deductible 20%, after deductible 20%, no deductible Outpatient Diagnostic Lab, Radiology Emergency Care 10% 10%, deductible waived 20%, after deductible 20%, no deductible Ambulance 10% 20, after deductible 20%, after deductible 20%, no deductible Urgent Care Center 10% 10%, after deductible 20%, after deductible 20%, after deductible Hospital Emergency Room $50 copayment; waived if admitted $50 copayment; waived if admitted. Behavioral Health Services Inpatient Mental Health and Substance Abuse Treatment Outpatient Mental Health and Substance Abuse Treatment Outpatient Therapy Services Chemotherapy Physical Therapy Occupational Therapy Respiratory Therapy Speech Therapy 20%, after deductible 0%, no deductible 10% 10%, after deductible 20%, after deductible 20%, after deductible 10% $0 copayment $0 copayment $0 copayment $10 copayment per visit 60 visit limit for each of the following services: Physical Therapy (excluding Chiropractic) Occupational Therapy Respiratory Therapy Speech Therapy 10%, after deductible 20%, after deductible 20%, no deductible Revised 03/2016 Page 3

4 Prescription Drug Coverage Retail Quantity Tier 1 Medications Tier 2 Medications Tier 3 Medications STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON maintenance and non-maintenance $5 copayment for a 30-day supply or for a 90-day supply per for a 30-day supply or $45 copayment for a 90-day supply per $30 copayment or 25%, whichever is greater, for a 30-day supply per. $90 copayment or 25%, whichever is greater, for a 90-day supply per Wellmark Drug List for all Plans (Select Blue Rx Complete) maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per Tier 4 Medications Same as Tier 3 Same as Tier 3 Same as Tier 3 Same as Tier 3 Mail Order Prescription Drugs Tier 1 Medications $10 copayment for each prescription up to a 90 day supply $10 copayment for each $10 copayment for each $10 copayment for each Tier 2 Medications Tier 3 Medications Tier 4 Medications $30 copayment for each prescription up to a 90 day supply prescription up to a 90 day supply prescription up to a 90 day supply $30 copayment for each $30 copayment for each $30 copayment for each Pharmacy Out-of-Pocket Maximum Single $5,850 Family $11,700 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Revised 03/2016 Page 4

5 Glossary of Benefit Terms Deductible Not Applicable Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. Deductible Copayment A fixed amount you pay for a Copayment A fixed amount you pay for a covered Copayment covered health care service, usually health care service, usually when you when you receive the service. receive the service. In-Network Tier 4 Limited-value Max out-of-pocket (MOP) Providers who contract with your health plan. Your payments may be less when seeking treatment from an in-network facility or physician. Limited-value are combination products, lifestyle, or with more costeffective options available on lower tiers (i.e. generics) This is the most you could pay during a coverage period (usually one calendar year) for your share of the cost of covered services. This limit helps you plan for health care expenses. In-Network Tier 4 Limitedvalue Max out-of-pocket (MOP) Providers who contract with your health plan. Your payments may be less when seeking treatment from an in-network facility or physician. Limited-value are combination products, lifestyle, or with more cost-effective options available on lower tiers (i.e. generics) This is the most you could pay during a coverage period (usually one calendar year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The in-network health and drug card maximum out of pocket amounts accumulate separately. Note: Emergency Room copayment continues to apply after out-of-pocket limit is met. In-Network Tier 4 Limitedvalue Max out-of-pocket (MOP) The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. A fixed amount you pay for a covered health care service, usually when you receive the service. Not Applicable Limited-value are combination products, lifestyle, or with more costeffective options available on lower tiers (i.e. generics) This is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Single $750 Medical MOP $5,850 Rx MOP $6,600 Total MOP Family $1,500 Medical MOP $11,700 Rx MOP $13,200 Total MOP Single $650 Medical MOP $500 Rx MOP $1,150 Total MOP Family $1,450 Medical MOP $1,000 Rx MOP $2,450 Total MOP Single $650 Medical MOP $500 Rx MOP $1,150 Total MOP Family $1,450 Medical MOP $1,000 Rx MOP $2,450 Total MOP Revised 03/2016 Page 5

6 Revised 03/2016 Page 6

Benefit Coverage Chart & Rates Effective July 1, 2014 June 30, 2015

Benefit Coverage Chart & Rates Effective July 1, 2014 June 30, 2015 Benefit Coverage Chart & Rates Effective PPO Medical Coverage by Category The following coverages are included with the PPO plan: o Prescription o Vision Additional Benefits o Dental o Dental & Orthodontia

More information

Benefit Coverage Chart & Rates

Benefit Coverage Chart & Rates Benefit Coverage Chart & Rates Effective July 1, 2014- June 30, 2015 PPO Medical Coverage by Category The following coverages are included with the PPO plan: o Prescription o Vision Additional Benefits

More information

Operating Engineers Public Employees Health and Welfare Trust Fund Plan D vs PERS CHOICE and PERS SELECT PPO Plan

Operating Engineers Public Employees Health and Welfare Trust Fund Plan D vs PERS CHOICE and PERS SELECT PPO Plan Calendar Year Deductible $500 Individual / $1,000 Family per calendar year Does not apply to PPO physician office visits, PPO preventive care or hospital emergency room charges for an emergency medical

More information

Health Insurance Matrix 01/01/16-12/31/16

Health Insurance Matrix 01/01/16-12/31/16 Employee Contributions Family Monthly : $121.20 Bi-Weekly : $60.60 Monthly : $290.53 Bi-Weekly : $145.26 Monthly : $431.53 Bi-Weekly : $215.76 Monthly : $743.77 Bi-Weekly : $371.88 Employee Contributions

More information

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations

More information

BlueSelect Silver ValueTwo for Individuals

BlueSelect Silver ValueTwo for Individuals BlueSelect Silver ValueTwo for Individuals Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single Plan Type: PPO This is only

More information

Medical Plan Comparison - Retirees Age 65 or Over

Medical Plan Comparison - Retirees Age 65 or Over * Plan Type Medicare Cost Plan with Prescription Coordinates with Medicare and includes Medicare prescription drug program Medicare Cost Plan with Prescription Medicare Advantage Plan with Prescription

More information

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15 S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem BlueCross BlueShield Blue Access PPO Option D58 / Rx Option 8 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family

More 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 https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.

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

Northeastern University 2015 Medical Benefits

Northeastern University 2015 Medical Benefits Northeastern University 2015 Medical Benefits Northeastern s 2015 Open Enrollment Effective Date: January 1, 2015 2015 Medical Plan Options Blue Choice New England Core POS Plan New Plan Blue Choice New

More information

Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Coverage Period: 01/01/2015-12/31/2015

Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Coverage Period: 01/01/2015-12/31/2015 Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015

More information

MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF BENEFITS

MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF BENEFITS Fiscal Year 2015 2016 MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: HealthKeepers Anthem HealthKeepers 20 POS / $10/$20/$35/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family

More information

University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Coverage Period: 01/01/2015-12/31/2015

University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Coverage Period: 01/01/2015-12/31/2015 University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual/Family

More information

LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-870-3057. Important Questions

More information

Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier PPO 400/20%/20%

Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier PPO 400/20%/20% Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier 400/20%/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:

More information

Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60)

Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60) Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60) Summary of Benefits and Coverage: What this Plan Covers & What it Costs

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: PPO Student/Affiliate Plan MIT Student/Affiliate Extended Insurance Plan Coverage Period: 2014-2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Couple,

More information

Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions

More information

You can see the specialist you choose without permission from this plan.

You can see the specialist you choose without permission from this plan. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pekininsurance.com or by calling 1-800-322-0160. Important

More information

Boston College Student Blue PPO Plan Coverage Period: 2015-2016

Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This is only a

More information

Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015

Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Only Plan Type: PPO This is only

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

Health Insurance Matrix 07/01/012-06/30/13

Health Insurance Matrix 07/01/012-06/30/13 Employee Contributions Family Monthly : $212.14 Bi-Weekly : $106.07 Monthly : $388.36 Bi-Weekly : $194.18 Monthly : $429.88 Bi-Weekly : $214.94 Monthly : $677.30 Bi-Weekly : $338.65 Employee Contributions

More information

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No.

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More 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? Anthem Blue Cross Stanislaus County: Custom EPO Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type:

More information

Pace University CIGNA Medical Detailed Benefit Summaries July 1, 2015 - June 30, 2016

Pace University CIGNA Medical Detailed Benefit Summaries July 1, 2015 - June 30, 2016 Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Deductible $1,300/$2,600 (Cumulative) N/A N/A Coinsurance

More information

2015 Health Benefits

2015 Health Benefits 2015 Health Benefits Product Cost Sharing - Member's Responsibility Health Care Reform Compliant Health Care Reform Compliant Health Care Reform Compliant Deductible (DED) (Per Person/Family Aggregate)

More information

$0 See the chart starting on page 2 for your costs for services this plan covers.

$0 See the chart starting on page 2 for your costs for services this plan covers. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/lausd or by calling 1-800-700-3739. Important

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem BlueCross BlueShield WI 2-99 Lumenos Health Savings Account POS Copay Option 4 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2014-11/30/2015 Coverage

More information

Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014

Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014 Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type:

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

Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO

Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary

More information

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

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 BlueCross BlueShield Healthcare Plan of Georgia Premier Plus POS Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family

More information

BlueOptions 1424. In-Network: Not Applicable. Out-Of- Network: $500 Per Person. Does not apply to In-Network preventive care.

BlueOptions 1424. In-Network: Not Applicable. Out-Of- Network: $500 Per Person. Does not apply to In-Network preventive care. BlueOptions 1424 Coverage Period: 01/01/2014-12/31/2014 All Copay Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: PPO/EPO This

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

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? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More 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

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436. Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.

More information

Administered by Capital BlueCross 1

Administered by Capital BlueCross 1 Administered by Capital BlueCross 1 PPO HRA Plan/Rx Plan This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at

More information

$500 Individual / $1,500 Family Does not apply to preventive care and pharmacy

$500 Individual / $1,500 Family Does not apply to preventive care and pharmacy This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mhhealthplan.org or by calling 1-713-338-6535 or 1-888-642-5040.

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.arcsvs.com or by calling 1-877-309-2955. Important Questions

More information

Health Plans Comparison Chart

Health Plans Comparison Chart Health Plans Comparison Chart PPO Deductible Coinsurance (Plan pays) Annual Out-of-Pocket Maximum (Medical) (all medical s, deductibles and coinsurance for covered services will apply. Once limit is met,

More information

Important Questions Answers Why this Matters: Non-Network $ 250 person / $ 500 family.

Important Questions Answers Why this Matters: Non-Network $ 250 person / $ 500 family. Lincoln Park Public Schools: Medical Benefits Coverage Period: 11/01/2012 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:

More information

Avera Health Employee Health Plan Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage:

Avera Health Employee Health Plan Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www. or by calling 1 (888) 322-2115. Important Questions

More information

OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVE and RETIRED PARTICIPANTS

OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVE and RETIRED PARTICIPANTS Employee Premium None None None None None Explanation of Plans and Options Available to You Deductible Annual Out-of-Pocket Calendar Year (Applicable to members who reside in California & Nevada Only.)

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

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem BlueCross Premier HMO 20 / $10/$25/$45/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage For: Individual/Family Plan Type:

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

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem Blue Cross Life and Health Insurance Company Unify: PPO Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family

More information

OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVES and EARLY RETIREES

OPERATING ENGINEERS HEALTH & WELFARE FUND BENEFIT PLANS SUMMARY COMPARISON FOR ACTIVES and EARLY RETIREES PPO Kaiser Permanente For Non-PPO Providers Employee Premium None None None None None Explanation of s and Options Available to You If you choose a doctor who is not contracted with Anthem Blue Cross the

More information

BlueOptions 1424. In-Network: Not Applicable. Out-Of- Network: $500 Per Person. Does not apply to In-Network preventive care.

BlueOptions 1424. In-Network: Not Applicable. Out-Of- Network: $500 Per Person. Does not apply to In-Network preventive care. BlueOptions 1424 Coverage Period: 01/01/2016-12/31/2016 All Copay Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: PPO/EPO This

More information

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual

More information

Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses?

Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses? Yale Health Plan: Faculty, Managerial & Professional, Post-doctoral Associates and Fellows Coverage Period: 1/1/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage

More information

$500 member / $1,000 family Self- Referred. Does not apply to emergency room, emergency transportation, or acupuncture services.

$500 member / $1,000 family Self- Referred. Does not apply to emergency room, emergency transportation, or acupuncture services. Blue Choice New England Plan 2 MIT Choice Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Ind.+Spouse, Ind.+Child(ren)

More information

HUMANA MEDICAL PLAN, INC:

HUMANA MEDICAL PLAN, INC: HUMANA MEDICAL PLAN, INC: Humana Platinum 1000/South Florida HUMx (HMOx) Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage

More information

Highlights of your Health Care Coverage

Highlights of your Health Care Coverage MEDICAL COST SHARE OPTIONS Individual Deductible PCY (Family deductible 2X Individual) Coinsurance (Member's percentage of costs after deductible based on allowable charges) Individual Out of Pocket Maximum

More information

HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015

HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: HMO This is only

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

Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016

Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual

More information

Massachusetts. Coverage Period: 7/1/2013 6/30/2014 Coverage for: Individual + Family Plan Type: HMO

Massachusetts. Coverage Period: 7/1/2013 6/30/2014 Coverage for: Individual + Family Plan Type: HMO Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 7/1/2013

More information

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

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 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.kaiserpermanente.org or by calling 1-800-464-4000. Important

More information

Coverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. Important Questions Answers Why this Matters:

Coverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gallagherkoster.com/colgate or by calling 1 877-371-9621.

More information

Kraft Foods Group, Inc. Retiree Medical and Prescription Plan Summary High Deductible Health Plan

Kraft Foods Group, Inc. Retiree Medical and Prescription Plan Summary High Deductible Health Plan General Provisions Deductible (eligible medical and prescription drug expenses apply to the deductible) Kraft Foods Group, Inc. Retiree Medical and Prescription Plan Summary Care can be obtained in-network

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

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Student Employee Health Plan: NYS Health Insurance Program Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family

More information

Important Questions Answers Why this Matters: $1,500 Individual/$3,000

Important Questions Answers Why this Matters: $1,500 Individual/$3,000 Anthem Blue Cross Life and Health Insurance Company Unify: Consumer Choice HSA Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:

More information

Massachusetts. Coverage Period: 01/01/2013 12/31/2013 Coverage for: Individual + Family Plan Type: HMO

Massachusetts. Coverage Period: 01/01/2013 12/31/2013 Coverage for: Individual + Family Plan Type: HMO Massachusetts Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013 12/31/2013 Coverage

More information

Board of Huron County Commissioners : BASIC

Board of Huron County Commissioners : BASIC This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions

More information

The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits.

The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim HMO - Primary Choice Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 07/01/2015 06/30/2016

More information

Regence BlueCross BlueShield of Oregon: Regence Oregon Standard Bronze Plan Coverage Period: Beginning on or after 01/01/2014

Regence BlueCross BlueShield of Oregon: Regence Oregon Standard Bronze Plan Coverage Period: Beginning on or after 01/01/2014 Regence BlueCross BlueShield of Oregon: Regence Oregon Standard Bronze Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning on or after 01/01/2014 Coverage

More information

Even though you pay these expenses, they don t count toward the out-ofpocket limit.

Even though you pay these expenses, they don t count toward the out-ofpocket limit. Commonwealth of Virginia: COVA Care Basic Coverage Period: 07/01/2014 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This

More information

StudentBlue University of Nebraska

StudentBlue University of Nebraska Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more details about

More information

benefit summary BAXTER COUNTY

benefit summary BAXTER COUNTY benefit summary BAXTER COUNTY benefit summary Effective Date: BAXTER COUNTY 01/01/2015 welcome Arkansas Blue Cross and Blue Shield is pleased to be your health insurance company. This Benefit Summary gives

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

2016 Plan Comparison For HealthFlex Exchange Participants

2016 Plan Comparison For HealthFlex Exchange Participants 2016 Plan Comparison For HealthFlex Exchange Participants This comparison highlights key differences and similarities between plans offered through HealthFlex Exchange in 2016. All plans use the same network

More information

Highmark Health Insurance Company: Health Savings Blue PPO 1300

Highmark Health Insurance Company: Health Savings Blue PPO 1300 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkblueshield.com or by calling 1-888-510-1064.

More information

BlueOptions 03160. Coverage Period: 01/01/2015-12/31/2015 HSA Compatible with Rx $15/$50/$80 after In-network Deductible

BlueOptions 03160. Coverage Period: 01/01/2015-12/31/2015 HSA Compatible with Rx $15/$50/$80 after In-network Deductible BlueOptions 03160 Coverage Period: 01/01/2015-12/31/2015 HSA Compatible with Rx $15/$50/$80 after In-network Deductible Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage

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

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

PPO Hospital Care I DRAFT 18973

PPO Hospital Care I DRAFT 18973 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.ibx.com or by calling 1-800-ASK-BLUE. Important Questions

More information

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual

More information

Personal Blue PPO QHDHP $5,000/$10,000

Personal Blue PPO QHDHP $5,000/$10,000 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 1-800-962-2242. Important

More information

MCPHS University Health Insurance Program Information

MCPHS University Health Insurance Program Information MCPHS University Health Insurance Program Information Beginning September 1, 2014 Health Services MCPHS University students on the Boston campus have access to the Massachusetts College of Art and Design

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? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/cuhealthplan or by calling 1-800-735-6072.

More information

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

What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your medical/vision coverage and costs, you can get the complete terms in the policy or plan document at www.mycigna.com, by calling 1-800-Cigna24,

More information

Summary Table of Benefits Select Medicare Supplement Plan

Summary Table of Benefits Select Medicare Supplement Plan 2016 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare

More 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

Schedule of Benefits Summary. Health Plan. Out-of-network Provider

Schedule of Benefits Summary. Health Plan. Out-of-network Provider Schedule of Benefits Summary University Name: University of Nebraska - Student Plan Health Plan : 2014/2015 Academic Year (see attached) Payment for Services Covered Services are reimbursed based on the

More information

PPO In the U.S. Non-Preferred Benefits PLAN FEATURES. (In-Network)

PPO In the U.S. Non-Preferred Benefits PLAN FEATURES. (In-Network) Group Insurance Plan of Benefits for The Church of Jesus Christ of Latter-Day Saints-Senior Missionaries Individual Deductible None $2,000 per plan year $2,000 per plan year Family Deductible None $4,000

More information

Important Questions. Why this Matters:

Important Questions. Why this Matters: Old National Bancorp: Blue Access (PPO) - 850 Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO

More information

Massachusetts. Coverage Period: 07/01/2014 06/30/2015 Coverage for: Individual + Family Plan Type: HMO

Massachusetts. Coverage Period: 07/01/2014 06/30/2015 Coverage for: Individual + Family Plan Type: HMO Massachusetts Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO-WSHG Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:

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

What is the overall deductible?

What is the overall deductible? Regence BlueCross BlueShield of Oregon: Innova Coverage Period: 10/01/2013-09/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family

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.summit-inc.net or www.yctrust.net or by calling Summit

More information

Schenectady City School District HEALTH BENEFIT COMPARISON ALL PLANS

Schenectady City School District HEALTH BENEFIT COMPARISON ALL PLANS FEATURES Members can choose to go to ANY PROVIDER or HOSPITAL they choose. Out of pocket expenses will always be lower when using in-network providers and facilities. To find a provider visit www.bsneny.com

More information