2016 PSE Schedule of Benefits - Premium
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- Myrtle Chandler
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1 2016 PSE Schedule of Benefits - Premium (Active, COBRA & Non-Medicare Retiree) Annual Deductible - Individual $1,000 $2,000 Annual Coinsurance/Copay Limit - Individual $2,500 N/A *Medical Out-of-Pocket Max $3,500 N/A Annual Deductible - Family $2,000 $4,000 Annual Coinsurance/Copay Limit - Family $5,000 N/A *Medical Out-of-Pocket Max - Family $7,000 N/A The Plan will pay 100 percent for individuals on family coverage if they reach the individual out-of-pocket maximum Paid By Plan After Satisfaction Of Deductible 80% 60% *Deductible, coinsurance and copays are included. COVERED BENEFITS AND SERVICES ADVANCED IMAGING *Advanced Imaging (Radiology Services) $0 20% 40% Y *Requires pre-certification *Charges will not apply when provided in conjunction with Emergency Room or Inpatient Hospital Services ALLERGY SERVICES Specialist Office Visit $50 0% 40% N Testing and Serum Formulation $0 20% 40% Y Injections $0 $0 40% N *Formulation of allergy serum requires coinsurance AMBULANCE SERVICES Air Ambulance Transportation Ground Transportation *Limited Benefits: $2,000 per member per trip for ground ambulance 10% $50 copay N N BEHAVIORAL/MENTAL HEALTH & SUBSTANCE ABUSE TREATMENT SERVICES Office Visit $25 0% 40% N Psychological Testing $35 0% 40% N In-Patient Services $0 20% 40% Y Outpatient Services (Partial Hospital/Day Treatment) $0 20% 40% Y Outpatient Services (Intensive Outpatient) $0 20% 40% Y Residential Treatment $0 20% 40% Y DENTAL SERVICES Page 1 of 5
2 Repair to Non-Diseases Teeth Due to Accident/Injury $0 20% 40% Y Page 2 of 5
3 COVERED BENEFITS AND SERVICES DIABETES MANAGEMENT SERVICE Insulin Pump & Supplies $0 20% 40% Y Glucometers $0 20% 40% Y Diabetic Self Management Training $0 0% 40% N *Lancets and insulin needles for diabetics will be paid 100% by the plan for participants in the Diabetic Management Program *Test strips must be purchased at Pharmacy Only. *Glucometers - Provided through DME/Medical Benefit DURABLE MEDICAL EQUIPMENT/ENTERAL FEEDING DME/Enteral Feeding $0 20% 40% Y *Coverage is provided for medically necessary durable medical equipment. See exclusions. Not all services require pre-certification and may be reviewed for medical necessity by AHH. Refer to Utilization Management section. HEARING SERVICES Hearing Screening $50 0% $50 N *Limited Benefits: One screening every three years Hearing Aid $0 0% 0% N *Limited Benefits: $1,400 per ear every three years HOME HEALTH SERVICES Home Health Services $0 20% 40% Y HOME INTRAVENOUS DRUGS Home Intravenous Drugs and Solutions $0 20% 40% Y HOSPICE SERVICES Hospice Care $0 20% 40% Y HOSPITAL SERVICES In-Patient Services $0 20% 40% Y Outpatient Services $0 20% 40% Y Diagnostic Services $0 20% 40% Y Emergency Room Visit and Observation Services $250 0% 0% N *ER copay may be waived. See Summary Plan Description (SPD) Urgent Care Center $100 0% 0% N *Visits deemed non-emergency will be treated as hospital services/outpatient. Page 3 of 5
4 COVERED BENEFITS AND SERVICES MATERNITY AND FAMILY PLANNING SERVICES Prenatal and Postnatal Outpatient Care $0 20% 40% Y Inpatient Maternity Services $0 20% 40% Y *Hospital length of stay for childbirth: This plan complies with federal law that prohibits restricting benefits for any hospital length of stay in connection with childbirth for the mother and newborn child to less than 48 hours following a normal vaginal delivery or less than 96 hours following a caesarean section delivery Infertility Diagnostic Evaluation: Office Visit $50 0% 40% N Infertility Testing $0 20% 40% Y *Treatment for infertility is not a covered benefit under the ARBenefits Plan. Services related to infertility are covered up to diagnosis. Testing is not covered during or following treatment. PHARMACY BENEFIT - REFER TO RX DRUG COVERAGE SECTION Prescription - Generic - Tier I $15 Prescription - Preferred - Tier II $40 Prescription - Non-Preferred - Tier III $80 Prescription Specialty - Tier IV $100 *RX Out-of-Pocket Max (Individual/Family) $3100/$6200 *Excluded drugs, reference price drugs and brand drugs where generic is available does not apply towards the RX Out-of-Pocket Max. PHYSICIAN/SPECIALIST SERVICES *Primary Care Physician Office Visit $25 $0 40% N *Specialist Office Visit/Specialty Care Services $50 $0 40% N *Other Physician Services provided under Outpatient or In-Patient Care** $0 20% 40% Y *Includes such services as debridement and/or wound dressing changes performed in an outpatient setting with or without direct physician attention * *Medication $0 20% 40% Y *This includes injectable, oral and intravenous medications Radiation Therapy $0 20% 40% Y **See Professional Services under SPD - Summary of Common Services PREVENTATIVE CARE SERVICES Physical Exams/Preventative Care $0 0% 40% N Well Baby/Child Care Visits $0 0% 40% N Immunizations $0 0% 0% N PROSTHETIC AND ORTHOTIC DEVICES Prosthetic and Orthotic Devices and Services $0 20% 40% Y REHABILITATION SERVICES (INPATIENT) Page 4 of 5
5 Rehabilitation Services $0 20% 40% Y COVERED BENEFITS AND SERVICES REHABILITIATION SERVICES (OUTPATIENT) OR OFFICE VISIT Chiropractic $25 0% 40% N *Limited Benefit: Fifteen (15) visits per member per plan year Physical Therapy $25 0% 40% N Occupational Therapy $25 0% 40% N Speech Therapy $25 0% 40% N *Therapy services billed by or provided by a Specialist MD will have the Specialist Copay ($50) SKILLED NURSING FACILITY (SNF) SERVICES SNF Services $0 20% 40% Y TEMPOROMANDIBULAR JOINT (TMJ)/DYSFUNCTION (TMD) SERVICES TMJ/TMD $0 20% 40% Y *Limited Benefit: $1,000 per member per plan year TRANSPLANT SERVICES Organ/Bone Marrow Transplant $250 20% 40% N *Copayment applicable per admission. *Limited Benefit: Two (2) organ transplants of the same organ per member per lifetime. *Limited Benefit: $10,000 lifetime limit for travel and lodging determined by EBD as reasonable and necessary in conjunction with transplant services. *Coverage is provided for transplant services subject to pre-authorization (See Utilization Management Section). Transplant services MUST be provided by approved transplant providers and facilities. VISION SCREENING Vision Screening $50 0% $50 N *Limited Benefit: One (1) exam every twenty-four (24) months Certain Limitations Apply - Please check your SPD Exclusions and Limitations section for more information Page 5 of 5
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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
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
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
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
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.
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)
Preauthorization Requirements * (as of January 1, 2016)
OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations
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
Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.
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
Are there other deductibles for specific services?
Blue Shield of CA Life & Health Active Choice Plan 750 Coverage Period: 04/01/2015-03/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.summit-inc.net or www.yctrust.net or by calling Summit
Student Health Insurance Plan Insurance Company Coverage Period: 07/01/2015-06/30/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.