Benefits at a Glance. Catholic Volunteer Network Policy Number: 06542A
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1 Benefits at a Glance Catholic Volunteer Network Policy Number: 06542A
2 Catholic Volunteer Network Benefits at a Glance Policy #06542A Effective September 1, 2015 Catholic Volunteer Network offers Medical, Pharmacy, and Medical Evacuation and Repatriation benefits to our employees through Cigna Global Health Benefits. This comprehensive global healthcare program allows our employees to access quality healthcare anywhere in the world. The following pages provide a general overview of the plan design for our employees on international assignment. This plan provides minimum essential coverage. Global Medical Plan Eligibility Lifetime Maximum International (Outside of the U.S.) U.S In-Network Refer to eligibility definition in the certificate Unlimited U.S Out-of-Network Plan Year Deductible Per Individual $100 $100 $100 Coinsurance (The percentage of covered expenses the plan pays) Out of Pocket Maximum Per Individual Includes Deductible Accumulation Physician Services Physician s Office Visit Surgery performed in physician s office Allergy testing/treatment Adult Preventive Care Travel Immunizations (For employee and dependents immunizations as required for travel) Immunizations Includes diphtheria, hepatitis A, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, Haemophilus influenza B Prescription Drug Benefit (Purchased outside the U.S.) 80% 80% 60% $2,000 $2,000 $2,000 Accumulation of Plan Deductible, Coinsurance and Out-of-Pocket Maximums: Deductible, Coinsurance and Out-of-Pocket Maximums will cross-accumulate between In-Network, Out-of-network and International. All other plan maximums and service specific maximums (dollar and occurrence) will also cross-accumulate. 80% after 80% after 80% after 80% after 80% after 80% after 80% after Refer to the Prescription Drug Benefits schedule 60% after 60% after 60% after Refer to the Prescription Drug Benefits schedule
3 Global Medical Plan Mammogram Ages 35-39: One baseline exam Ages 40-49: One exam every one or two years for asymptomatic women, but no sooner than two years after a women s baseline Age 50 & Over: One exam annually Any age: Whenever prescribed by a physician Women s Preventive Services Annual well-woman visits Gestational diabetes screening Domestic violence screening and counseling Papanicolaou (Pap) Screening Test (One test per calendar year for females) Prostate Cancer Screening (One test per calendar year for males) Colorectal Cancer Screening (Age 50 and older or any high-risk individual) Inpatient Hospital Services Facility Physician International (Outside of the U.S.) 80% after 80% after U.S In-Network 80% after 80% after U.S Out of Network 60% after 60% after Outpatient Facility Services 80% after 80% after 60% after Hospital Emergency Room (Refer to certificate for coverage and exclusions) Skilled Nursing Facility (120-day maximum per calendar year combined) 80% after 80% after 80% after (Except if not a true emergency, then 60% after ) 80% after 80% after 60% after Lab & Radiology Facility 80% after 80% after 60% after Outpatient Short-Term Rehabilitation Therapy (60-day maximum per calendar year for all therapies combined) Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab and Cognitive Therapy. Note: Short-Term Rehabilitation Therapy maximum does not apply to the treatment of Autism. Chiropractic Services (U.S. Out of Network 20-day maximum per calendar year, unlimited U.S. In-Network and International visits ) 80% after 80% after 60% after 80% after 80% after 60% after
4 Global Medical Plan International (Outside of the U.S.) U.S In-Network U.S Out of Network Home Health Care (120-day Maximum per calendar year) 80% after 80% after 60% after Hospice 80% after 80% after 60% after Maternity Care Services 80% after 80% after 60% after Breast-feeding equipment and supplies (Limited to one rental of one breast pump per birth as ordered or prescribed by a physician. Includes related supplies and counseling) Family Planning: Women s Services Inpatient hospital facility Outpatient hospital facility Surgical services such as tubal ligation are covered (excluding reversals) Family Planning: Men s Services Inpatient hospital facility Outpatient hospital facility Surgical services such as vasectomy are covered (excluding reversals) Infertility (Procedures directly related to diagnosis are covered. Treatment, prescription drugs, and/or other method to bypass, i.e., In-vitro, are not covered. Refer to the certificate for additional coverage and exclusions) 80% after 80% after 60% after 80% after 80% after 60% after Durable Medical Equipment 80% after 80% after 60% after External Prosthetic Appliances 80% after 80% after 60% after Diabetes Equipment 80% after 80% after 60% after TMJ (Benefit Lifetime Maximum: $1,000) 80% after 80% after 60% after Hearing Exam: One every 24 month period Dental Care (Accident) (Limited to a continuous course of treatment started within six months of accidental injury to sound natural teeth) Mental Illness and Substance Abuse Inpatient Outpatient 80% after 80% after 60% after 80% after 80% after 60% after 80% after 80% after 80% after 80% after 60% after 60% after
5 Prescription Drug Benefits Purchased Inside the United States Only Retail Drugs Benefit Highlights Participating Pharmacy (U.S. In-Network) The amount you pay for each 30 Non-Participating Pharmacy (U.S. Out-of-Network) The amount you pay for each 30 Generic 20% not subject to 20% after Preferred Brand Name 20% not subject to 20% after Home Delivery Prescription Drugs The amount you pay for each 90 The amount you pay for each 90 Generic 20% not subject to U.S. In-Network coverage only Preferred Brand Name 20% not subject to U.S. In-Network coverage only Emergency Medical Evacuation / Repatriation Toll Free telephone number: Emergency Evacuation Family Travel Arrangements Repatriation of Mortal Remains 100% of covered expenses not subject to the for services approved by International SOS Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7 days 100% coverage
6 Global Wellness Programs Pre-Assignment Assistance Program Health & Well-Being Assessment Cigna Global Health Benefits pre-assignment assistance is a unique clinical program that offers comprehensive case management, care coordination, inpatient management, evacuation assistance, and online expert second opinions for employees and dependents either in the U.S. or abroad. The tool can be accessed prior to or during assignment through Cigna's secure web portal, Employees that utilize the pre-assignment assistance program are more likely to have a successful assignment. The Health and Well-Being Assessment (HA) is a short, online assessment that is core to our wellness solutions and the first step to identifying personal health risks. Those who complete the HA receive a personalized health risk profile report. The HA is medically validated by the World Health Organization. Pre-Admission Certification/ Continued Stay Review for Hospital Confinement Precertification for inpatient and outpatient services received in the U.S. is required. Network providers must call our toll-free number, to precertify services. The customer is responsible for ensuring that out-of-network providers precertify services. Failure to obtain precertification may affect out-of-pocket costs. This is a summary only and further details can be found in the insurance certificate. Cigna Global Customer Service Toll Free telephone number: Direct Telephone Toll Free fax number: Direct fax number: Secure Website Mail Delivery: Courier Delivery: (collect calls accepted) Registration is required. (See member kit for registration information.) Secure available at this site. Cigna Global Health Benefits P.O. Box Wilmington, DE U.S.A. Cigna Global Health Benefits 300 Bellevue Parkway Wilmington, DE U.S.A. The information herein is believed accurate as of the date of publication and is subject to change. This material is intended for informational purposes only and contains only a partial and general description of benefits. Please consult your policy/customer certificate for a complete description of coverage and exclusions. In the event of a conflict or discrepancy, the terms of the formal plan documents control. Please contact your Plan Administrator for a copy of the plan documents. Coverage and benefits are contingent upon the applicable policy terms and are available except where prohibited by applicable law. Copyright 2015 (Cigna Corporation) Publication Date 9/2/15 BSC
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Blue Cross Premier Bronze Extra
An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network
HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC.
HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible
FCPS BENEFITS COMPARISON Active Employees and Retirees Under 65
FCPS S COMPARISON Medical Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Individual Annual Deductible None $250 None $250 None Family Annual Deductible Limit None $500 None $500 None
SPIN Effective Date: 01-01-2013 Aetna HealthFund Aetna Choice POS ll - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
HealthFund Amount $1,500 Employee $1,500 Employee + 1 Dependent $1,500 Employee + 2 Dependents $1,500 Family Amount contributed to Fund by employer Fund Coinsurance 100% Percentage at which Fund will reimburse
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
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
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
IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)
HMO-OA-CNT-30-45-500-500D-13 HMO Open Access Contract Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations
State Health Plan: Savings 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 at www.eip.sc.gov or by calling 1-888-260-9430. Important Questions
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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 Benefit Booklet twww.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions
Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip
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
IL Small Group PPO Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- PPO HSA HDHP $2,500 100/80 (04/09)
PLAN FEATURES OUT-OF- Deductible (per calendar ) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015
Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015 About this chart: This chart is to be used as a guide only and does not contain all details or exclusions.
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
CATEGORY AFSCME Comprehensive Plan OU PPO
APPENDIX B BENEFIT PLAN SUMMARY CHART CATEGORY AFSCME Comprehensive Plan OU PPO Premiums 2010-2011 Plan Year 2010-2011 Plan Year Annual Wages: $0 - $34,600 $13.50 EE only $24.00 EE + Child $24.00 EE +
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)
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to