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

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

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

Transcription

1 SCHEDULE OF BENEFITS Classes of Employees Insured: [Class 1 All Active Full-Time Indian Employees] [Monthly Premium Rates: Individual - [$ ] Two-Person [$ ] Family Coverage [$1,210.66]] Benefit Plan: Bronze POS Standard Plan Out-of-Network Maximum Be aware that your actual costs for services provided by an out-of-network provider may exceed this policy s maximum out-of-pocket for out-of-network services. Your costs for the following covered services do not accumulate toward the maximum out-of-pocket amount if delivered by an out-of-network provider: Dental Services, Vision Services and Prescription Drug Services. In addition, out-of-network providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and that amount is not counted toward the out-of-network maximum out-of-pocket. BENEFIT INFORMATION OUT-OF-NETWORK Maximum Lifetime Benefit Per Covered Person Deductible Individual Deductible (per Covered Person per Calendar Year) Family Deductible (per family per Calendar Year) Annual Out-of-Pocket Maximum Individual Annual Out-of-Pocket Maximum (per Covered Person per Calendar Year) Family Annual Out-of-Pocket Maximum (per family per Calendar Year) Unlimited $3,950 $7,900 $6,350 $12,700 Unlimited $7,900 $12,000 $12,000 $15,000 Coinsurance 5 7 MHC-4400-V1-LINK-BRZ-SOB 1 ID

2 COVERED BENEFITS SCHEDULE OF BENEFITS (continued) This Policy will pay Covered Medical Expenses incurred for Covered Benefits provided in Section 5, Covered Benefits: (1) based on the Allowable Fee; and (2) unless otherwise indicated below, subject to the Deductible, Coinsurance, and Annual Out-of-Pocket Maximum amounts shown under the Benefit Information section of this Schedule of Benefits. If a Copayment applies to a Covered Benefit, it will be indicated below in this Covered Benefits section. COVERED BENEFIT All Covered Benefits shown in Section 5, unless otherwise specified below in this Schedule of Benefits 5 after Deductible Daily Hospital Room and Board 5 after Deductible Miscellaneous Hospital Services 5 after Deductible Surgical Services 5 after Deductible Anesthesia Services 5 after Deductible In-Hospital Medical Services 5 after Deductible Out-of-Hospital Care 5 after Deductible Maximum Dollar Amount for Covered Charges $6350 Unlimited In Network Unlimited Out of Network Chemical Dependency Inpatient/Outpatient Facility Office Visit 5 after Deductible $35 Copay per visit Chiropractic Services Maximum Number of Office Visits per Calendar Year 20 visits Convalescent Home Services Maximum Number of Days per Calendar Year 60 days 5 after Deductible 5 after Deductible Durable Medical Equipment Rental (up to the purchase price), Purchase and Repair and Replacement of Durable Medical Equipment Preauthorization is recommended for original 5 after Deductible MHC-4400-V1-LINK-BRZ-SOB 2 ID

3 COVERED BENEFIT purchase or replacement of Durable Medical Equipment over $500. Emergency Room Services 5 after Deductible 5 after Deductible Home Health Care Services Maximum Number of Home Visits per Calendar Year 180 days 5 after Deductible MHC-4400-V1-LINK-BRZ-SOB 3 ID

4 SCHEDULE OF BENEFITS (continued) COVERED BENEFIT Laboratory Services 5 after Deductible Mental Health Services Inpatient/Outpatient Facility Office Visit 5 after Deductible $35 Copay per visit Physician Medical Services Physician Office Visits (Non- Specialist) Physician Specialist Visits $35 Copay per visit 5 after Deductible (The payment amount applies to office visits for all Covered Benefits except for Preventive Health Care Services.) Prescription Drugs Benefit Retail Pharmacy Prescriptions (31-day supply) Generic Drugs-Tier 1 Preferred Brand Drugs-Tier 2 Non-Preferred Brand and Generic Drugs-Tier 3 Specialty Drugs-Tier SP Mail Order Maintenance (90- day supply) Generic Drugs-Tier 1 Preferred Brand Drugs-Tier 2 Non-Preferred Brand and Generic Drugs-Tier 3 Specialty Drugs-Tier SP $15 after Deductible $115 after Deductible $150 after Deductible $175 after Deductible $30 after Deductible $230 after Deductible $300 after Deductible $350 after Deductible $15 after Deductible $115 after Deductible $150 after Deductible $175 after Deductible $30 after Deductible $230 after Deductible $300 after Deductible $350 after Deductible Must pay ancillary charge if brand named is chosen and generic is available 100 Dose Quantity Limit You must pay an Ancillary Charge in addition to the Deductible and/or Copayment, as applicable, if You choose a Brand-Name drug when a Generic drug is available. If you choose an out of network pharmacy, you are responsible for any amounts over the allowed amount. Preventive Health Care Services 10 Covered, Deductible and Annual Out-of-Pocket Maximum do not apply Prostheses Benefit (Non-Dental) 5 after Deductible MHC-4400-V1-LINK-BRZ-SOB 4 ID

5 COVERED BENEFIT Rental (up to the purchase price) Purchase, Repair, Replacement of Prosthetics Preauthorization recommended for the original purchase or replacement of prosthetics over $500 Therapeutic Services Outpatient 5 after Deductible Transplant Services 5 after Deductible MHC-4400-V1-LINK-BRZ-SOB 5 ID

6 SCHEDULE OF BENEFITS (continued) COVERED BENEFIT Vision Care Benefit Pediatric Vision Care Services This Vision Care Benefit only applies to Covered Dependent Children under age 19. Vision Care Services Vision Examination Frequency of Services: One Vision Examination per Covered Dependent Child per Calendar Year None, 10 Covered One Vision Examination per Covered Dependent Child per Calendar Year Vision Care Materials Lenses Single Vision Bifocal Trifocal Lenticular None, 10 Covered* None, 10 Covered* None, 10 Covered* None, 10 Covered* One set of lenses per Covered Dependent Child per Calendar Year *Coverage includes lenses in polycarbonate, plastic or glass, scratch resistant or UV coatings also covered. Frequency of Services: One set of lenses per Covered Dependent Child per Calendar Year Vision Care Materials Frames Frequency of Services: One frame per Covered Dependent Child per Calendar Year. Frame selection will be from a Pediatric Exchange Collection. None, 10 Covered One frame per Covered Dependent Child per Calendar Year. Contact Lenses Necessary Professional Fees and Materials Elective Professional Fees** and Materials None, 10 Covered*** None, 10 Covered*** *** *** **15% discount applies to the Provider s usual and customary professional fees for contact lens evaluation and fitting ***The following service limitations apply to In-Network benefits for Contact Lenses: (1) Standard (one pair annually) = 1 contact lens per eye (total 2 lenses); (2) Monthly (six-month supply) = 6 lenses per eye (total 12 lenses); (3) Bi-weekly (3 month supply) = 6 lenses per eye (total 12 lenses); and (4) Dailies (one month supply) = 30 lenses per eye (total 60 lenses). MHC-4400-V1-LINK-BRZ-SOB 6 ID

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

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 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 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

2016 Health, Dental and Vision Monthly Contributions

2016 Health, Dental and Vision Monthly Contributions 2016 Health, Dental and Vision Monthly Contributions Benefit Plan Monthly Contributions for Active Regular Full-Time and Part-Time Employees Employee Only Spouse Child(ren) Family Dental: Cigna PPO $ 12

More information

OUTLINE OF COVERAGE. Individual Engage Comprehensive Health Insurance Policy

OUTLINE OF COVERAGE. Individual Engage Comprehensive Health Insurance Policy OUTLINE OF COVERAGE Individual Engage Comprehensive Health Insurance Policy Policy Number: [123456] Policy Effective Date: [January 1, 2016] Policyowner: [John Doe] Policy Anniversary Date: [January 1

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

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

US Airways Medicare Options US Trust 2015 Benefits Guide

US Airways Medicare Options US Trust 2015 Benefits Guide US Airways Medicare Options US Trust 2015 Benefits Guide Welcome to the 2015 Medicare Options US Trust Retiree Benefit Plans This guide includes detailed information regarding the benefit options available

More information

Mountain Health CO-OP [1545 E Iron Eagle Dr. Ste 103 Eagle, ID 83616 Customer Service: (855) 488-0622]

Mountain Health CO-OP [1545 E Iron Eagle Dr. Ste 103 Eagle, ID 83616 Customer Service: (855) 488-0622] Mountain Health CO-OP [1545 E Iron Eagle Dr. Ste 103 Eagle, ID 83616 Customer Service: (855) 488-0622] OUTLINE OF COVERAGE INDIVIDUAL ACCESS CARE CATASTROPHIC HEALTH INSURANCE COVERAGE Policy Form MHC-4000

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

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

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

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

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

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

2015 Summary of Healthcare Plan Changes

2015 Summary of Healthcare Plan Changes 2015 Summary of Healthcare Plan Changes Change Plan names the OA POS plan becomes the Comprehensive Care Plan and the HSA OA POS plan becomes the Consumer Choice HSA plan Comprehensive Care Plan Increase

More information

Coventry Health & Life Insurance Company

Coventry Health & Life Insurance Company 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:

More information

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

The Railroad Employees National Vision Plan

The Railroad Employees National Vision Plan The Railroad Employees National Vision Plan Effective January 1, 2013, your Vision Plan benefits will be provided by EyeMed Vision Care. There is no change to the Plan design but there will be a few enhancements.

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

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

In-network: $5,000 per insured/ $10,000 per family per calendar year. Out-of-network: $10,000 per insured / $20,000

In-network: $5,000 per insured/ $10,000 per family per calendar year. Out-of-network: $10,000 per insured / $20,000 Regence BlueShield of Idaho: Coverage Period: Beginning on or after 01/01/2014 Regence Individual Direct Bronze HSA Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:

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

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

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

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 Summary Plan Description (SPD) or Plan Document at www.pebtf.org or by calling 1-800-522-7279.

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

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

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

More information

Summary of Benefits and Coverage What this Plan Covers & What it Costs

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 plan document at www.mpiphp.org or by calling 1-855-275-4674. Important Questions Answers

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

Benefits Summary UNUM - Group Term Life/AD&D & Voluntary Life/AD&D Plan

Benefits Summary UNUM - Group Term Life/AD&D & Voluntary Life/AD&D Plan UNUM - Group Term Life/AD&D & Voluntary Life/AD&D Plan Benefits Summary Basic employee life insurance 1x base annual earnings rounded to the next higher $1,000 to a maximum benefit of $300,000 Supplemental

More information

Healthy Benefits HMO 6850.0

Healthy Benefits HMO 6850.0 Coverage Period: Beginning on or after 1/1/2016 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 https://www.capbluecross.com/sbcsia

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: BridgeSpan Health Company: Exchange Silver Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible

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

Coverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters:

Coverage for: Individual, Family 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.bbsionline.com or by calling 1-866-927-2200. Important

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

BRYN MAWR COLLEGE MEDICAL INSURANCE BENEFITS COMPARISON EFFECTIVE NOVEMBER 1, 2009

BRYN MAWR COLLEGE MEDICAL INSURANCE BENEFITS COMPARISON EFFECTIVE NOVEMBER 1, 2009 BENEFITS Description of Plan Annual Deductible (January - December) - Individual - Family PERSONAL CHOICE PPO BRYN MAWR COLLEGE KEYSTONE HEALTH PLAN EAST KEYSTONE POS Provides comprehensive health Provides

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

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

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

BridgeSpan Health Company: BridgeSpan Oregon Standard Gold Plan MyChoice Northwest

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

More information

2014 Annual Enrollment Guide

2014 Annual Enrollment Guide 2014 Annual Enrollment Guide Intel Retiree Medical Plan Annual Enrollment is October 28 to November 15, 2013 Enroll at the My Health Benefits website www.intel.com/go/myben or call (877) GoMyBen (466-9236)

More information

Regence BlueCross BlueShield of Utah: Regence Direct Silver HSA

Regence BlueCross BlueShield of Utah: Regence Direct Silver HSA Regence BlueCross BlueShield of Utah: Regence Direct Silver HSA Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual &

More information

$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other. deductibles for specific No.

$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other. deductibles for specific 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 capbluecross.com or by calling 1-800-730-7219. Important

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

2015 Charts & Rates. Benefit Comparison Charts & Rates

2015 Charts & Rates. Benefit Comparison Charts & Rates 2015 Charts & Rates Comparison Charts & Rates Medical Options This is not the complete Medical Comparison Chart. Refer to the Medical Summary Plan Description or the Legal Notices on the enclosed CD for

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

LEGACY PLAN Medical In-Ntwk Out-of-Ntwk

LEGACY PLAN Medical In-Ntwk Out-of-Ntwk Preventive Services Age, gender and frequency criteria Adult physical/immunizations Well child visits/immunizations Screenings 0 Co-Insurance (after deductible) Out-of-Pocket Maximums Office Visit (copays)

More information

Health Plan Comparison Chart

Health Plan Comparison Chart Open Enrollment 2014 State Employee Health Plan Health Plan Comparison Chart & other information For Active State Employees 2013 **Cover photo is titled Road into the Field from the Postcards from Kansas

More information

GEHA 2015. A complete guide to GEHA Health Plans. (800) 262-GEHA geha.com The Benefits of Better Health

GEHA 2015. A complete guide to GEHA Health Plans. (800) 262-GEHA geha.com The Benefits of Better Health GEHA 2015 A complete guide to GEHA Health Plans (800) 262-GEHA geha.com The Benefits of Better Health Your choice of three health plans, with more doctors and hospitals and member cost savings for: Doctor

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

National Automatic Sprinkler Industry Welfare Fund. Benefits Highlights

National Automatic Sprinkler Industry Welfare Fund. Benefits Highlights National Automatic Sprinkler Industry Welfare Fund Benefits Highlights 2014 This Benefits Highlights booklet does not contain the full plan document and is not a Summary Plan Description for the NASI Welfare

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

BluePrint Bronze Tribal Zero Cost Share Plan 458a Coverage Period: Beginning on or after 01-01-2015

BluePrint Bronze Tribal Zero Cost Share Plan 458a Coverage Period: Beginning on or after 01-01-2015 BluePrint Bronze Tribal Zero Cost Share Plan 458a Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage Period: Beginning on or after 01-01-2015 Coverage for: Single and family

More information

BlueConnect HSA Bronze $3,500 Plan 457 Coverage Period: Beginning on or after 01-01-2015

BlueConnect HSA Bronze $3,500 Plan 457 Coverage Period: Beginning on or after 01-01-2015 BlueConnect HSA Bronze $3,500 Plan 457 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage Period: Beginning on or after 01-01-2015 Coverage for: Single or 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? 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

Coverage Comparison Chart

Coverage Comparison Chart Coverage Comparison Chart Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans $500-Deductible PPO Alaska Plan $1,000-Deductible PPO Alaska Plan CDHP $1,500-Deductible HSA-qualifed

More information

Companion Life Insurance Company: Middlebury College Student Health Insurance Plan Coverage Period: 08/15/2015-08/14/2016

Companion Life Insurance Company: Middlebury College Student Health Insurance Plan Coverage Period: 08/15/2015-08/14/2016 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.

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

2015 Charts & Rates. Benefit Comparison Charts & Rates

2015 Charts & Rates. Benefit Comparison Charts & Rates 2015 Charts & Rates Benefit Comparison Charts & Rates Medical Benefit Options This is not the complete Medical Comparison Chart. Refer to the Medical Summary Plan Description or the Legal Notices on the

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Minimum Coverage 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

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

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

Aetna Medicare Advantage HMO SHBP Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Aetna Medicare Advantage HMO SHBP 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.state.nj.us/treasury/pensions/health-benefits.shtml or

More information

2016 Annual Enrollment Guide for Intel Retirees

2016 Annual Enrollment Guide for Intel Retirees 2016 ANNUAL ENROLLMENT GUIDE FOR RETIREES 1 2016 Annual Enrollment Guide for Intel Retirees Intel s Annual Enrollment is October 26 through December 15, 2015* Choose benefits to power your best life. Enroll

More information

Find the plan that s right for you

Find the plan that s right for you Take a glance at what our plans have to offer Plans at a glance for s and families Effective January 1, 2014 Find the plan that s right for you Our easy-to-understand plans offer comprehensive benefits

More information

Individual and Family Plans

Individual and Family Plans Effective: January 1, 2015 Individual and Family Plans find a plan that fits you live by your own plan a plan for your life Everyone s needs are unique, and it s important to find a plan that best fits

More information

2 Medical Health Insurance Plans Dental Plan Option Vision Plan Option

2 Medical Health Insurance Plans Dental Plan Option Vision Plan Option STUDENT OSTEOPATHIC MEDICAL ASSOCIATION 2013-2014 SCHOOL YEAR PLAN SUMMARIES COLLEGE HEALTH INSURANCE PROGRAM 2 Medical Health Insurance Plans Dental Plan Option Vision Plan Option The 2013-2014 complete

More information

GEHA 2014. A complete guide to GEHA Health Plans. (800) 262-GEHA geha.com The Benefits of Better Health

GEHA 2014. A complete guide to GEHA Health Plans. (800) 262-GEHA geha.com The Benefits of Better Health GEHA 2014 A complete guide to GEHA Health Plans (800) 262-GEHA geha.com The Benefits of Better Health Your choice of three health plans, with more doctors and hospitals and member cost savings for: doctor

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

ADVANCED SCIENCE BASIC HEALTH CARE PLAN

ADVANCED SCIENCE BASIC HEALTH CARE 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.loomisco.com or by calling 1-800-346-1223. Important

More information

Answers. Why this Matters:

Answers. Why this Matters: Aetna HDHP What is the overall deductible? Do I need a referral to see a specialist? Are there this plan doesn't cover? Yes. This is only a summary. If you want more details about your coverage and costs,

More information

: THE LASIK VISION INSTITUTE, LLC : Aetna Choice POS II - Coverage Period: 03/01/2014-02/28/2015

: THE LASIK VISION INSTITUTE, LLC : Aetna Choice POS II - Coverage Period: 03/01/2014-02/28/2015 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.healthreformplansbc.com or by calling 1-888-982-3862.

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

National Guardian Life Insurance Company: Earlham College Student Health Insurance Plan Coverage Period: 08/01/2015-07/31/2016

National Guardian Life Insurance Company: Earlham College Student Health Insurance Plan Coverage Period: 08/01/2015-07/31/2016 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.studentplanscenter.com or by calling 1-800-756-3702.

More information

Your Out-of-Pocket Type of Service

Your Out-of-Pocket Type of Service Calendar Year Deductible (CYD) 1 $5,000 single/ 2x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,000 single/ 2x family maximum. With respect to family plans,

More information

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. 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.healthchoiceessential.com/members/member_benefits.aspx

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

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

: MARSH & MCLENNAN COMPANIES :

: MARSH & MCLENNAN COMPANIES : 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.aetna.com or by calling 1-866-374-2662. Important Questions

More information

VA Innovation Health Silver $10 Copay

VA Innovation Health Silver $10 Copay 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.innovation-health.com/summary-benefits-and-coverage or

More information

Summary of Benefits and Coverage What this Plan Covers & What it Costs - 2015

Summary of Benefits and Coverage What this Plan Covers & What it Costs - 2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.mpiphp.org or by calling 1-855-275-4674. Important Questions Answers

More information

HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC

HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC and HUMANA INSURANCE COMPANY: Humana National Preferred Silver 4250/6250 Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage:

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

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.cfhp.com or by calling 1-800-434-2347. Important Questions

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 PacificSource.com or by calling 1-888-977-9299 Important

More information

Kaiser Permanente: KP DC Silver 1750/25%/HSA/Dental/PedDental Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:

Kaiser Permanente: KP DC Silver 1750/25%/HSA/Dental/PedDental Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Kaiser Permanente: KP DC Silver 1750/25%/HSA/Dental/PedDental Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Coverage Period: Plan Type: HDHP This is only a summary.

More information

Aetna Choice POS II - High Plan

Aetna Choice POS II - High 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.healthreformplansbc.com or by calling 1-888-982-3862.

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

Human Energy. Yours. TM

Human Energy. Yours. TM Human Energy. Yours. TM Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage What This Plan Covers and What it Costs Coverage Period January 1, 2015 December 31,

More information

: MARSH & MCLENNAN COMPANIES: Aetna HealthFund Aetna Choice POS II - HSA $1500 DED

: MARSH & MCLENNAN COMPANIES: Aetna HealthFund Aetna Choice POS II - HSA $1500 DED 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.aetna.com or by calling 1-866-374-2662. Important Questions

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

2015 Charts & Rates. Benefit Comparison Charts & Rates

2015 Charts & Rates. Benefit Comparison Charts & Rates 2015 Charts & Rates Comparison Charts & Rates Medical Options This is not the complete Medical Comparison Chart. Refer to the Medical Summary Plan Description or the Legal Notices on the enclosed CD for

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

HUMANA HEALTH PLAN, INC:

HUMANA HEALTH PLAN, INC: HUMANA HEALTH PLAN, INC: Humana Silver 4600/Lexington UK Healthcare 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

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? 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.

More information

National Guardian Life Insurance Company: Rider University International Student Health Insurance Plan Coverage Period: 08/20/2015-08/20/2016

National Guardian Life Insurance Company: Rider University International Student Health Insurance Plan Coverage Period: 08/20/2015-08/20/2016 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.

More information

Blue Cross Blue Shield: Select 6350 Package VH, a Multi-State Plan Coverage Period: 01/01/2014-12/31/2014

Blue Cross Blue Shield: Select 6350 Package VH, a Multi-State Plan Coverage Period: 01/01/2014-12/31/2014 Blue Cross Blue Shield: Select 6350 Package VH, a Multi-State Plan Coverage Period: 01/01/2014-12/31/2014 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan

More information

Community HealthEssentials. 2014 Guide

Community HealthEssentials. 2014 Guide Community HealthEssentials 2014 Guide Community HealthEssentials - Summary Community HealthEssentials is the new name for Community Health Plan of Washington s (CHPW) individual commercial products offered

More information