Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip
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1 HOSPITAL SERVICES Hospital Inpatient : Paid in full, Non-network: Hospital charges subject to 10% of billed charges up to coinsurance maximum. Non-participating provider charges subject to Basic Medical Program. Lesser of $200 or 20% (surgery) No cost No cost No cost Hospital Outpatient Hospital/: $40 or $60 per visit;hospital/non-participating Provider: Hospital charges $40 or $60 per visit. Non-participating provider charges subject to BasicMedical;NonnetworkHospital/Non-participating Provider: Hospital charges subject to $90 (may be less for non-surgical) 10%of billed charges or a $75 copayment, whichever is greater up to coinsurancemaximum. Non-participating Provider charges subject to BasicMedical $10 per visit $150 max depending on location $120 max depending on location Ambulance No copayment if service is provided by admitting hospital. $35 $100/trip $50/trip $75/trip $50/trip Emergency Room $60 or $70/visit No copayment. $100/visit $50/visit $75/visit $75/visit Urgent Care $15 or $20/visit $35/visit $10/visit $50/visit $25/visit Skilled Nursing Facility No cost up to 365 benefit days. No benefit if Medicare primary. No cost: 45 days per admission up to a maximum of 360 lifetime limit No cost up to 50 days No cost up to 45 days No cost up to 45 days Hospice No cost; unlimited No cost; 210 days No cost; unlimited No cost; unlimited No cost; 210 days Page 1
2 PHYSICIAN SERVICES Office Visit $15 or $20/visit $25/visit, no cost annual exam or well child $10/visit; no cost for well child care $20/visit, no cost for well child visits $25/visit; $10 PCP sick visits for children to age 25 Specialty Office Visit $15 or $20/visit $40/visit $10/visit $20/visit $40/visit Annual Routine Physical $15 or $20/visit No Cost $10/visit No Cost No Cost Allergy Testing / Treatment $15 or $20/visit Contact carrier Contact carrier Contact carrier Contact carrier Chiropractic $15 or $20/visit $40/visit $10/visit $20/visit $40/visit Family Planning $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Infertility Services $40 Outpatient $15 or $20/visit; no cost at designated Center of Excellence; $50,000 lifetime maximum $40/visit $10/visit $20/visit (physician's office), $75/visit (outpatient surgery center) $25/visit Page 2
3 Contraceptive Drugs/ Devices $15 or $20/visit. Also covered by prescription drug program subject to copayment. Applicable prescription copay applies Applicable prescription copay applies. Applicable prescription copay applies No cost WOMEN'S HEALTH CARE Pap Tests $40/outpatient visit $15 or $20/visit No cost for routine visit No cost No cost No cost Mammograms $40/outpatient visit $15 or $20/visit No cost for routine visit No cost No cost No cost Pre/Post Natal No cost $5 for the first 10 visits No cost No cost $25 copayment per pregnancy Bone Density Tests $40/outpatient visit $15 or $20/visit No cost for routine visit $10/visit No cost No cost DIAGNOSTIC / THERAPEUTIC SERVICES X-Rays $40/outpatient visit $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Lab Tests $40/outpatient visit $15 or $20/visit $25/visit No cost $20/visit No cost Page 3
4 Pathology No Cost $15 or $20/visit $25/visit No cost $20/visit No cost EKG/EEG $40/outpatient visit $15 or $20/visit $40/visit $10/visit $20/visit $25/visit Radiation / Chemo No Cost No cost Radiation $25/Chemo $50 $10/visit $20/visit Radiation $40/visit; Chemotherapy $40/visit MENTAL HEALTH / SUBSTANCE ABUSE Inpatient Mental Health No cost; unlimited when medically necessary (OptumHealth) No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Mental Health $15 or $20/visit; unlimited when medically necessary (OptumHealth) $40/visit; unlimited $10/visit; unlimited $20/visit; unlimited $25/visit; unlimited Page 4
5 Inpatient Drug / Alcohol Rehab No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Drug / Alcohol Rehab $15 or $20/visit to approved program; unlimited when medically necessary (OptumHealth) $25/visit; unlimited $10/visit; unlimited $20/visit; unlimited $25/visit; unlimited PRESCRIPTION DRUGS Prescription Drugs *Note: 3-tier system (generic, preferred brandname drugs, and nonpreferred brand-name drugs) Mail order OR retail pharmacy, 30 day supply: $5, $15, or $40. Mail order day supply: $5, $20, or $65. Pharmacy day supply: $10, $30, or $70. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name copayment plus the difference in cost between the brand-name drug and its generic equivalent. $10/$30/$ days mail order: $20/$60/$100. Open formulary. $5/$15/$ days mail order: $15/$45/$105. $5/$15/$ days mail order: day copayments $10/$30/$ days mail order: $25 generic/$75 brand/$125 non-formulary. Open formulary MISCELLANEOUS Centers of Excellence for Cancer and/or Transplant No cost at designated Centers of Excellence. Precertification required. N/A N/A N/A N/A Page 5
6 Diabetic Supplies No cost. Call HCAP for participating providers. $25/item; 30 day supply $10/item $20/item $25 copayment per boxed item/31 day supply Home Health Care No cost. Call HCAP for participating providers. Contact carrier Contact carrier $20/visit, max 40 visits Contact carrier Durable Medical Equipment No cost. Call HCAP for participating providers. 50% coinsurance 20% coinsurance 50% coinsurance 50% coinsurance Orthotics Paid in full 50% coinsurance 20% coinsurance No cost 50% coinsurance Prosthetics Paid in full. 50% coinsurance 20% coinsurance No cost 50% coinsurance Rehabilitative Care (PT, OT, Speech) Inpatient: no cost; $15 or $20/visit for PT following surgery or hospitalization $15 or $20/visit Inpatient: no cost up to 60 days. Outpatient: $40/visit up to 30 visits combined for: PT, Speech and OT Inpatient: no cost up to 45 days. Outpatient: $10/visit; max 20 visits. Inpatient: No cost up to 45 days. Outpatient: $20/visit up to 20 visits per year Inpatient: no cost, two month max; Outpatient: $40/visit up to 30 visits Alternative Medicine: Nutrition, Acupuncture, Massage Therapy Discount for network provider Contact carrier - Discounts available Contact carrier - Discounts available Contact carrier - Discounts available Each policy receives $100 to spend on health, wellness, and fitness programs. Contact for additional programs. Page 6
7 Dental (preventive) Not covered Not covered Preventive: 20% discount at select providers; free second annual exam $50/cleaning; 20% discount on additional services at select providers $25/visit for children up to 19 Hearing Aids up to $1200 or $1500 per aid per ear every 4 years (every 2 years for children). Covered in full every three years for children Not covered under 19. Discounts Available at select providers Not covered Vision (routine) Not covered $40/exam associated with disease or injury. Discount from participating providers $10/visit once/year. $25/exam every 24 months Page 7
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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.
January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1
January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we
Western Health Advantage: City of Sacramento HSA ABHP Coverage Period: 1/1/2016-12/31/2016
Coverage For: Self Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.westernhealth.com or
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
Services and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Not subject to deductible if PPO
Page 1 of 5 Individual Deductible Calendar year $400 COMBINED Individual / Family OOP Calendar year $4,800 Individual $12,700 per family UNLIMITED Annual Maximum July 1 st to June 30 th UNLIMITED UNLIMITED
Summary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)
Summary of Benefits January 1, 2016 December 31, 2016 FIRSTCAROLINACARE INSURANCE COMPANY FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties This booklet
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
SCAN Health Plan. 2015 Summary of Benefits
SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8713_2014F File & Use Accepted 09032014 SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with
2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how