CARECONNECT NORTHWELL HEALTH EMPLOYEE PLAN SCHEDULE OF BENEFITS. Participating Provider Member Responsibility for Cost-Sharing
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1 CARECONNECT NORTHWELL HEALTH EMPLOYEE PLAN SCHEDULE OF BENEFITS COST-SHARING Deductible Individual Family Medical Out-of-Pocket Limit Individual Family Pharmacy Out-of-Pocket Limit Individual Family Combined Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) None None $3,000 $6,000 $3,000 $6,000 $6,000 $12,000 Specialist Visits (or Home Visits) $35 Copayment Administered by CareConnect Administrative Services, Inc. 1
2 PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations Adult Immunizations Routine Gynecological Services/Well Woman Exams Mammography Screenings Sterilization Procedures for Women Vasectomy Bone Density Testing Screening for Prostate Cancer All other preventive services required by USPSTF and HRSA * * * * * * (PCP)/$35 Copayment (Specialist) * * * *When services are not provided in accordance with the comprehensive guidelines for preventive services supported by USPSTF and HRSA appropriate cost share for applicable services will apply (Primary Care Visit; Specialist Visit; Diagnostic Radiology Services; Laboratory Procedures, Diagnostic Testing, etc.) Administered by CareConnect Administrative Services, Inc. 2
3 EMERGENCY CARE Pre-Hospital Emergency Medical Services (Ambulance Services) Non-Emergency Ambulance Services $100 Copayment $100 Copayment Emergency Department $200 Copayment (Copayment waived if Hospital admission) Urgent Care Center PROFESSIONAL SERVICES AND OUTPATIENT CARE Advanced Imaging Services Performed in a Freestanding Radiology Facility or Setting Allergy Testing & Treatment Performed in a Specialist Ambulatory Surgical Center Facility Fee $20 Copayment at NSLIJ Urgi-Care (GoHealth); $40 Copayment all other locations $35 Copayment Administered by CareConnect Administrative Services, Inc. 3
4 Anesthesia Services (all settings) Autologous Blood Banking 10% Coinsurance See Benefits For Description Cardiac & Pulmonary Rehabilitation Performed in a Specialist See Benefits For Description Performed as Inpatient Chemotherapy Performed in a Specialist Included as part of Inpatient Hospital Service Cost Sharing Chiropractic Services Clinical Trials $35 Copayment Use Cost Sharing for Appropriate Service (Primary Care Visit; Specialist Visit; Surgery; Laboratory & Diagnostic Procedures) Administered by CareConnect Administrative Services, Inc. 4
5 Diagnostic Testing Performed in a Specialist Dialysis Performed in a Freestanding Center or Specialist Setting Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) Home Health Care Infertility Services (Basic & Comprehensive) No unless it includes sedation or anesthesia $35 Copayment No unless it includes sedation or anesthesia $35 Copayment $25 Copayment Use Cost Sharing for Appropriate Service ( Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) Dialysis Performed by Non- Participating Providers is limited to 10 visits per calendar year. (Subject to a $15 copayment) 60 visits per condition, per lifetime combined therapies 200 Visits per Plan Year Administered by CareConnect Administrative Services, Inc. 5
6 Artificial Insemination Assisted Reproductive Technology Infusion Therapy Performed in Specialist 100% covered at any CareConnect Participating Network Provider, no lifetime max 80% Covered up to 3 cycles/lifetime at Center of Human Reproductive Services (CHR) No. Services are only covered at CHR, located at 300 Community Drive, Manhasset Home Infusion Therapy Home infusion counts towards home health care visit limits Inpatient Medical Visits Laboratory Procedures Performed in a Freestanding Laboratory Facility or Specialist *Some genetic tests may require a Preauthorization *Some genetic tests may require a Preauthorization Administered by CareConnect Administrative Services, Inc. 6
7 Maternity & Newborn Care Prenatal Care Inpatient Hospital Services and Birthing Center Physician and Midwife Services for Delivery One (1) Home Care Visit is Covered at no Cost-Sharing if mother is discharged from Hospital early Breast Pump Postnatal Care Covered in Full Covered in Full Covered for duration of breast feeding Outpatient Hospital Surgery Facility Charge Preadmission Testing Diagnostic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Administered by CareConnect Administrative Services, Inc. 7
8 Therapeutic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) $25 Copayment 60 visits per condition, per lifetime combined therapies. Speech and Physical Therapy are only Covered following a Hospital stay or surgery. Second Opinions on the Diagnosis of Cancer, Surgery & Other Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) Inpatient Hospital Surgery Outpatient Hospital Surgery Surgery Performed at an Ambulatory Surgical Center Surgery $35 Copayment All transplants must be performed at designated Hospitals Administered by CareConnect Administrative Services, Inc. 8
9 ADDITIONAL SERVICES, EQUIPMENT & DEVICES ABA Treatment for Autism Spectrum Disorder Acupuncture Assistive Communication Devices for Autism Spectrum Disorder Diabetic Equipment, Supplies & Self-Management Education Diabetic Equipment, Supplies and Insulin (30- Day Supply) Diabetic Education Durable Medical Equipment & Braces $35 Copayment No Preauthorization required for up to 12 visits annually; Preauthorization required for visits 13 and up. 10% Coinsurance for items above $500 (all breast pumps require a Preauthorization) Administered by CareConnect Administrative Services, Inc. 9
10 External Hearing Aids and Hearing Aid Accessories Cochlear Implants Hospice Care Inpatient Outpatient for covered dependents under age 26 10% Coinsurance $15,000 limit per year. Maximum of one pair of external hearing aids per year. External hearing aid evaluation can only be performed by, and written recommendation for external hearing aid issued by, a Participating Provider who is a physician. Member is required to submit to CareConnect Administrative Services for reimbursement. One (1) per Ear while enrolled under this Certificate 210 Days per Plan Year Five (5) Visits for Family Bereavement Counseling Medical Supplies 10% Coinsurance Prosthetic Devices External Internal 10% Coinsurance Included as part of inpatient Hospital service Cost-Sharing One (1) prosthetic device, per limb, per lifetime Unlimited Administered by CareConnect Administrative Services, Inc. 10
11 INPATIENT SERVICES & FACILITIES Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) Observation Stay Notification Required Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) $250 per admission 200 Days Per Plan Year Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) 60 Consecutive Days Per Condition, Per Lifetime MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care (for a continuous confinement when in a Hospital) Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) No. (Outpatient therapies such as ECT requires a Preauthorization) Administered by CareConnect Administrative Services, Inc. 11
12 Inpatient Substance Use Services (for a continuous confinement when in a Hospital). Outpatient Substance Use Services Unlimited **PRESCRIPTION DRUGS Retail Pharmacy 30 Day Supply Tier 1 $0 Copayment Tier 2 $50 Copayment Tier 3 50% to maximum $500 Copayment Specialty (Designated Pharmacy) 20% to maximum $150 Copayment for Certain Drugs Note: Certain Assisted Reproductive Technology (ART) medication not on our formulary will be covered up to a $15,000 lifetime maximum and must be filled through Vivo Pharmacy Administered by CareConnect Administrative Services, Inc. 12
13 Up to a 90 Day Supply For Maintenance Drugs Tier 1 $0 Copayment Tier 2 $150 Copayment Tier 3 Mail Order Pharmacy Up to a 90 Day Supply Tier 1 50% to maximum $1,500 Copayment for Certain Drugs $0 Copayment Tier 2 $125 Copayment Tier 3 50% to maximum $1,250 Copayment Enteral Formulas Tier 1 Tier 2 Tier 3 for Certain Drugs $0 Copayment $50 Copayment 50% to maximum $500 Copayment **Please refer to the formulary for prior authorization, step therapy and quantity limits. Administered by CareConnect Administrative Services, Inc. 13
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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
UMC Health Plan Operations Coverage Period: 01/01/2013-12/31/2013
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.healthplanoperations@umchealthsystem.com or by calling
Aetna Whole Health Houston, TX: ES Coverage Period: 01/01/2014 12/31/2014
This is only a summary. Please read the FEHB Plan brochure RI 73-873 that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in
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.
UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 7EG of Educators Benefit Services, Inc. Enrolling Group Number: 717578 Effective Date: January 1, 2012
How Much Does Your Health Insurance Plan Cost?
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.deltahealthsystems.com or by calling the Benefits Help
BridgeSpan Health Company: BridgeSpan Oregon Standard Gold Plan MyChoice Northwest
BridgeSpan Health Company: BridgeSpan Oregon Standard Gold Plan MyChoice Northwest Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at
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 -
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 http://www.whyviva.com/memberaccess.aspx or by calling 1-800-294-7780.
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
$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)
$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.
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.pplusic.com or by calling 608-282-8900 (1-800-545-5015).
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
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
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON EFFECTIVE JANUARY 1, 2016
This comparison is only a summary of benefits. Benefits will be administered as described in each plan s Summary of Benefits & Coverage. For further details, refer to those documents or call Wellmark Blue