Benefit Coverage Chart & Rates
|
|
- Annabelle Taylor
- 8 years ago
- Views:
Transcription
1 Benefit Coverage Chart & Rates Effective July 1, June 30, 2015 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 o Life Insurance o Long Term Disability Deduction Note: The medical health care and dental rates are deducted on a pre-tax basis, while all other rates are post-tax. The contributions taken on a post-tax basis are those for Supplemental and Dependent Life, which are automatically deducted from your paycheck after taxes are taken out. Faculty Members: Benefit contributions for all faculty members will be deducted from September - May. Although the deductions are taken over a 9-month period, your benefit coverages last all year.
2 P P O MEDICAL PLAN July 1, June 30, 2015 Deductible The member must pay all costs up to this amount before the plan begins to pay for covered services. Some specific services, such as preventive care, do not apply to the deductible. See the coverage chart for more details. In-network and Out-of-Network accrue separately. Plan Co-Insurance A cost sharing feature in which the plan (Anthem Blue Cross Blue Shield) pays a fixed percentage of the cost of medical care. Employee Co-Insurance A cost sharing feature in which the Member pays a fixed percentage of the cost of medical care. PLAN YEAR MAXIMUMS Employee Co-Insurance Maximum Equal the total employees will pay for co-insurance during the plan year. Employee Out-of-Pocket Maximum Equals the total employees will pay in deductibles and coinsurance during the plan year. Employee Co-Pay Maximum Equals the total employees will pay for Office Visit co-pays during the plan year. Individual Lifetime Maximum Benefits Pre-Existing Condition Limitations A pre-existing condition is a physical or mental health condition, disability or illness that you have before you enrolled in a health plan. Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) TIER 1 TIER 2 (In-Network) (Out- of-network) $200/$400 $400/$800 90% for most categories 70% for most categories 10% for most categories 30% for most categories Out-of-pocket maximums accumulate separately; therefore, charges for out-of-network services cannot be applied to the in-network employee out-of-pocket maximum and vice versa $1000/$2000 $1200/$00 $5150/$10,300 None - $20 co-pay Unlimited $1500/$3000 $1900/$3800 Out of Network Co-Pay not applicable None - 70% reimbursement P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Ambulance (subject to medical necessity) Child Wellness Visits Anthem Blue Cross and Blue Shield Standards TIER 1 (In-Network) 100% reimbursement for eligible procedures TIER 2 (Out- of-network) Chiropractic Services Durable Medical Equipment Emergencies A medical emergency is defined by insurance company standards. May include a condition that if untreated could be life threatening or seriously impair bodily functions. Gynecological Exams/PAP Smears Preventive and Diagnostic Hearing NOTE: Hearing medical conditions are covered the same as any other condition. Hearing Aid & Supplies 12 visit limit per plan year $20 co-pay $50 co-pay The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit. 100% reimbursement One routine hearing exam covered per plan year (Under Preventive Care) $20 co-pay for office visit -90% reimbursement 70% reimbursement -70% reimbursement 2
3 P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Home Health Care Services 100 visit limit per plan year (Combined with Private Duty Nursing) Hospice Services Inpatient & Outpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) TIER 1 (In-Network) 100% reimbursement TIER 2 (Out- of-network) Mammograms Preventive and Diagnostic 100% reimbursement Maternity Pre and postnatal physician services $20 co-pay for first visit; afterwards 90% reimbursement Delivery: Vaginal & Cesarean Labs & Radiology Mental Health Inpatient and Residential Treatment Outpatient Counseling First 6 visits of plan year with an EAP/Impact or Anthem Network Provider 100% reimbursement After 6 visits - $20 co-pay Occupational Therapy Non Anthem Network Provider 40 visit limit per plan year (combined with Physical Therapy) Inpatient 90% reimbursement Outpatient $20 co-pay Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) Outpatient & Inpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) Physical Therapy Inpatient - $20 co-pay 40 visit limit per plan year (combined with Occupational Therapy) 90% reimbursement Outpatient $20 co-pay Prescription Plan Administered by Express Scripts Formulary list maintained and controlled by prescription benefits management company (PBM) and is subject to changes as directed by PBM. Preventive Care Anthem Blue Cross and Blue Shield Standards Retail Co-pays: Generic Drug $10 Brand Name Formulary $20 Brand Name Non-Formulary $30 Mail Order Co-pays: Generic Drug $15 Brand Name Formulary $30 Brand Name Non-Formulary $45 Generics Preferred Program and Exclusive Home Delivery Program Required 100% reimbursement for eligible procedures Second Surgical Opinion 100% reimbursement Skilled Nursing Facility Limited to 60 days. Case management available if applicable. Speech Therapy 30 visit limit per plan year Inpatient Outpatient $20 co-pay 3
4 P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Substance Abuse Inpatient and Residential Treatment Outpatient Counseling Surgery (inpatient, outpatient, doctor s office & other) TMJ TIER 1 (In-Network) First 6 visits of plan year with an EAP/Impact or Anthem Network Provider 100% reimbursement After 6 visits - $20 co-pay TIER 2 (Out- of-network) Non Anthem Network Provider Transplants (Transplant program is available) No specific maximums Urgent Care Facility $20 co-pay 70% reimbursement Vision Screening Anthem Blue Cross & Blue Shield Preventive Benefits Vision Administered by Vision Service Plan- VSP Classified Staff Faculty & Administrators L O N G T E R M D I S A B I L I T Y Preventive Vision Screening -100% reimbursement Preventive Vision Screening 70% reimbursement Vision is currently administered by Vision Service Plan (VSP). The administrator is subject to change. VSP pays for 1 exam, lenses or contact lenses, and frames every months for adults and 12 months for a dependent child. The reimbursement level for benefits depends on VSP s agreement with the provider. Call VSP directly at for further details. Exam: plan pays $25 for an exam every 12 months The plan pays for one of the following every months for adults and every 12 months for children: Single Vision Lenses.$45 Frames....$25 Bifocals. $55 Contact Lenses... $45 Trifocals... $75 Medically Necessary Contact Lenses...$150 VSP providers offer a 20% discount, contact directly at: Long-term disability insurance is provided for the employee and is available if an employee becomes totally disabled due to injury or disease. The benefit provides income equal to 60% of the employee s monthly earnings to a maximum of $6,000 per month, minus other income benefits such as Social Security or those provided by the State Teachers Retirement System or Ohio s Public Employees Retirement System. A D D I T I O N A L P R E M I U M S (if applicable, based on dependent eligibility: Spouse/Domestic Partner* Premium Employee's choosing to enroll their spouse or domestic partner in a health insurance plan are charged an additional $50 monthly premium if the spouse/partner is employed and not enrolled in his/her employer's health plan. If your spouse/partner is also employed by Ohio University, the additional premium will not apply. Extended Dependent Premium Additional premium charged for any Unmarried, Full Time Student dependents age to 28. Medical and Prescription Coverage ONLY available. Adult Child Premium Additional premium charged for any Non Full Time Student dependents age to 28. Medical and Prescription Coverage ONLY available. $33.33 $25.00 $23.08 $33.33 $25.00 $23.08 $ $ $ *Medical and dental benefits for a domestic partner are not eligible for the pre-tax deduction from the employee's wages. Additional expenses or taxable wages may be incurred. Refer to Ohio University Policy : Domestic Partner Benefits for more information. 4
5 P P O MEDICAL PLAN RAT ES Effective July 1, 2014 June 30, 2015 Salary Bracket B1 $0 $35,300 Employee Only $43.63 $32.72 $30.20 Employee plus One $87.25 $65.44 $60.41 Employee & Family $ $98.16 $90.61 B2 $35,301 $41,200 Employee Only $47.87 $35.90 $33.14 Employee plus One $95.75 $71.81 $66.28 Employee & Family $ $ $99.42 B3 $41,201 $46,400 Employee Only $52.11 $39.09 $36.08 Employee plus One $ $78.17 $72.15 Employee & Family $ $ $ B4 $46,401 $53,000 Employee Only $56.35 $42.27 $39.01 Employee plus One $ $84.53 $78.03 Employee & Family $ $1.79 $ B5 $53,001 $60,500 Employee Only $60.59 $45.45 $41.95 Employee plus One $ $90.89 $83.90 Employee & Family $1.78 $ $ B6 $60,501 $68,400 Employee Only $64.83 $48.63 $44.88 Employee plus One $ $97.25 $89.77 Employee & Family $ $ $ B7 $68,401 $79,900 Employee Only $69.07 $51.81 $47.82 Employee plus One $ $ $95.64 Employee & Family $ $ $ B8 $79,901 $98,200 Employee Only $73.32 $54.99 $50.76 Employee plus One $ $ $ Employee & Family $ $ $ B9 $98,201 + Employee Only $77.56 $58.17 $53.70 Employee plus One $ $ $ Employee & Family $ $ $ P P O MEDICAL PLAN RAT ES- Part-Time Classified (Hourly) Employees Benefit rates for part-time classified employees are based on the hours worked per pay period. Rates will be deducted each pay period and are based on the B1 salary bracket: 0-$35,300 Hours Worked per pay period Employee Only $ $ $70.38 $30.20 Employee plus One $ $ $ $60.41 Employee & Family $ $ $ $
6 D ENTAL COVERAGE Employee Dental (Free for full-time employees) Dependent Dental (Optional employee paid benefit) $25 deductible -80% Reimbursement up to a $750 plan year maximum Benefit per covered person: $25 deductible -80% Reimbursement up to a $750 plan year maximum D E N T A L R A T E S Effective July 1, 2014 June 30, 2015 Part-Time Classified (Hourly) Employees Part-time employees are eligible to purchase dental coverage for themselves and their dependents. However, employee dental must be purchased in order to cover dependents. ORTHODONTIA COV ERAGE (optional employee paid benefit) O R T H O D O N T I A R A T E S (Includes Dental Coverage) Effective July 1, 2014 June 30, 2015 Part-Time Classified (Hourly) Employees Part-time employees are eligible to purchase dental coverage for themselves and their dependents. However, employee dental must be purchased in order to cover dependents. Employee Only $0.00 $0.00 $0.00 Employee plus One $16.00 $12.00 $11.08 Employee & Family $30.00 $22.50 $20.77 Hours Worked per pay period Employee Only $10.15 $8.12 $6.09 $0.00 Employee plus One $30.92 $.74 $.55 $10.62 Employee & Family $41.08 $32.86 $.65 $20.77 Benefit per covered person: -50% Reimbursement up to a $1,000 lifetime maximum Employee Only $1.33 $1.00 $0.92 Employee plus One $.62 $14.00 $12.92 Employee & Family $34.00 $25.50 $23.54 Hours Worked per pay period Employee Only $11.08 $8.86 $6.65 $.92 Employee plus One $33.69 $.95 $20.22 $12.46 Employee & Family $44.77 $35.82 $.86 $23.54 Rev. 09/2014
7 LIFE INSURANCE COVERAGE Basic Life Insurance* 2.5 times annual pay to a maximum of $50,000 is provided free of charge for full-time employees Supplemental Life Insurance* Dependent Life Insurance** Employees may also purchase up to $500,000 of additional life insurance for themselves Employees may also purchase up to $20,000 of life insurance for their dependents *Accelerated life insurance, which allows employees to access up to one-half of their life insurance if they are deemed to be terminally ill, is included in the life insurance plans. ** Dependent Life coverage limited to age 23 for full-time students. LIFE INSURANCE RATES Effective July 1, 2014 June 30, 2015 B A S I C Part-Time Classified (Hourly) Employees Part-time employees must purchase Basic Life Insurance to be eligible to purchase supplemental and/or dependent life. S U P P L E M E N T A L (Rate quoted is per $10,000 unit) $0.00 $0.00 $0.00 Hours Worked per pay period $ 5.36 $ 4.02 $ 2.68 $ 1.34 AGE Under D E P E N D E N T ** **Dependent Life coverage limited to age 23 for full-time students. COVERAGE Spouse $5,000 Child $2,000** Option B Spouse 10,000 Child $5,000** Option A Spouse $20,000 Child $10,000** Option C Rev. 09/2014
8 Medical Dental Pre-cert Nurseline ( Hours) ( Hours) Rev. 6/ Rev. 09/2014
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
More informationCATEGORY 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 +
More informationYour 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 informationSTATE 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
More informationYour 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 informationKAISER PERMANENTE PLAN (Non-Medicare Eligible)
CEMENT MASONS HEALTH AND WELFARE TRUST FUND FOR NORTHERN CALIFORNIA RETIRED CEMENT MASONS AND THEIR ELIGIBLE DEPENDENTS EFFECTIVE JANUARY 1, 2015 GENERAL When You Can Change Plans Type of Plan, Service
More informationCalifornia 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 informationSherwin-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 informationOPERATING 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 informationWhen You Can Change Plans. Care is provided through physicians or medical staff at a Kaiser Permanente facility located in the member's service area.
CEMENT MASONS HEALTH AND WELFARE TRUST FUND ACTIVE CEMENT MASONS AND THEIR ELIGIBLE DEPENDENTS EFFECTIVE FEBRUARY 1, 2013 PLAN FEATURES DIRECT PAYMENT PLAN KAISER PERMANENTE When You Can Change Plans Type
More informationOPERATING 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 informationHealth 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 informationPrescription 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 informationYour Plan: Anthem Gold PPO 500/20%/4500 Your Network: Prudent Buyer PPO
Your Plan: Anthem Gold PPO 500/20%/4500 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 not reflect
More informationS c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
More informationS c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15
S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/14-6/30/15 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations
More informationHealth 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 informationMedical 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 informationKraft 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 information2015 Medical Plan Options Comparison of Benefit Coverages
Member services 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-800-464-4000 Web site www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/
More informationCarpenters Health & Welfare Trust Fund for California Retiree Plan Comparison
Carpenters Health & Welfare Trust Fund for California Retiree Plan Comparison Information Needed: Eligibility, Benefits, COBRA or Disability Claims: Indemnity Medical Plan Indemnity Hearing Aid Benefit
More informationOperating Engineers Public Employees Health and Welfare Trust Fund Plan D vs PERS CHOICE and PERS SELECT PPO Plan
Calendar Year Deductible $500 Individual / $1,000 Family per calendar year Does not apply to PPO physician office visits, PPO preventive care or hospital emergency room charges for an emergency medical
More informationWhat 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.
More informationBenefits 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 informationSERVICES IN-NETWORK COVERAGE OUT-OF-NETWORK COVERAGE
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 3838 N. Causeway Blvd. Suite 3350 Metairie, LA 70002 1-800-341-6613 SCHEDULE OF BENEFITS BENEFITS AND PRIOR AUTHORIZATION REQUIREMENTS ARE SET FORTH IN ARTICLES
More informationImportant 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
More information2013 IBM Health Benefit Comparison Charts
203 IBM Health Benefit Comparison Charts for IBM Active Employees These Health Benefit Comparison Charts provide a summary overview of the coverage available for medical services, mental health/substance
More informationWhat 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 information2016 HealthFlex Plan Comparison: PPO B1000 with HRA and HDHP H1500 with HSA
Caring For Those Who Serve 1901 Chestnut Avenue Glenview, Illinois 60025-1604 1-800-851-2201 www.gbophb.org 2016 HealthFlex Plan Comparison: PPO B1000 with HRA and HDHP H1500 with HSA Please note: This
More informationBEMIDJI STATE UNIVERSITY FACULTY (IFO) CANDIDATE BENEFITS SUMMARY
Human Resources Office May, 2014 BEMIDJI STATE UNIVERSITY FACULTY (IFO) CANDIDATE BENEFITS SUMMARY The benefits listed are subject to change pending state and federal legislation and changes in the negotiated
More informationFACULTY (IFO) CANDIDATE BENEFITS SUMMARY
Human Resources Office Rev. Jan. 2013 FACULTY (IFO) CANDIDATE BENEFITS SUMMARY The benefits listed are subject to change pending state and federal legislation and changes in the negotiated agreements.
More informationCost Sharing Definitions
SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable
More information2015 IBM Health Benefit Comparison Charts for IBM Active Employees
2015 IBM Health Benefit Comparison Charts for IBM Active Employees These Health Benefit Comparison Charts provide a summary overview of the coverage available for medical, mental health/substance care
More informationHealthy 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 informationSummary of PNM Resources Health Care Benefits Active Employees 2011
of PNM Resources Health Care Benefits Active Employees 2011 The following charts show deductibles, limits, benefit levels and amounts for the PNM Resources medical, dental and vision programs. For more
More informationYour Plan: Anthem Gold HMO 500/20%/5000 Your Network: California Care HMO
Your Plan: Anthem Gold HMO 500/20%/5000 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 not
More informationImportant 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 informationImportant 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
More informationMAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF BENEFITS
Fiscal Year 2015 2016 MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
More informationAnthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO
Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with
More informationROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area
Contacting the Carrier Voice: (877) 883-9577 TTY: (585) 454-2845 Website: Voice: (800) 665-7924 TTY: (800) 252-2452 Website: www.excellusbcbs.com www.mvphealthcare.com Deductible Carry Over None None Deductible,
More informationImportant 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 https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.
More informationHow 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
More informationHealth Insurance Benefits Summary
Independent licensee of the Blue Cross and Blue Shield Association Health Insurance Benefits Summary Community Blue SM PPO Health Maintenance Exam (1) Covered 100%, one per calendar year, includes select
More informationBlueSelect Silver ValueTwo for Individuals
BlueSelect Silver ValueTwo for Individuals Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single Plan Type: PPO This is only
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.
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 informationStudentBlue University of Nebraska
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more details about
More informationMember s responsibility (deductibles, copays, coinsurance and dollar maximums)
MICHIGAN CATHOLIC CONFERENCE January 2015 Benefit Summary This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations
More informationInternational 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 informationBlue 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
More informationLGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 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.anthem.com or by calling 1-800-870-3057. Important Questions
More informationCoverage 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 informationOpen. Enrollment. Welcome to
Open Welcome to Enrollment 2 0 1 0 Open enrollment for active full-time employees and eligible part-time faculty will take place from October 1 through October 31, 2009. Because LACCD is joining the CalPERS
More informationIn-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 informationSchedule of Benefits Summary. Health Plan. Out-of-network Provider
Schedule of Benefits Summary University Name: University of Nebraska - Student Plan Health Plan : 2014/2015 Academic Year (see attached) Payment for Services Covered Services are reimbursed based on the
More informationBowling 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
More informationSummary Table of Benefits Select Medicare Supplement Plan
2016 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare
More informationYour Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO
Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary
More informationCENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance
CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview
More informationWhat 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 informationLesser 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
More informationPLAN DESIGN AND BENEFITS POS Open Access Plan 1944
PLAN FEATURES PARTICIPATING Deductible (per calendar year) $3,000 Individual $9,000 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being
More information2016 Plan Comparison For HealthFlex Exchange Participants
2016 Plan Comparison For HealthFlex Exchange Participants This comparison highlights key differences and similarities between plans offered through HealthFlex Exchange in 2016. All plans use the same network
More informationPLUMBERS LOCAL 24 WELFARE FUND
PLUMBERS LOCAL 24 WELFARE FUND Quick Reference Guide for JOURNEYMEN Effective January 1, 2015 Important Notice: This is an outline of the principal plan provisions of the Plumbers Local 24 Welfare Plan
More informationImportant 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 informationAnthem 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 informationLand of Lincoln Health : Family Health Network LLH 3-Tier Bronze PPO Coverage Period: 01/01/2016 12/31/2016
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.landoflincolnhealth.org or by calling 1-844-FHN-4YOU.
More informationCoventry 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 informationSUMMARY 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 informationHealthy 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 informationMichigan Electrical Employees Health Plan Benefits & Eligibility-at-a Glance Supplement to Medicare - Medicare Enrollees
Medicare Coverage BCBSM Supp Coverage Preventive Services 12 months, if age 50 and older Colonoscopy - one per calendar year 1 0 years (if at high risk every 24 months) approved amount**, once per flu
More informationHealth Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.
Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.
More informationSummary 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 informationHealth Insurance Overview
Spotsylvania County Open Enrollment August 10 to 28, 2015 Plan Year: October 1, 2015 to September 30, 2016 Health Insurance Overview All Full Time employees are eligible to participate in the County Health
More informationEmployee + 2 Dependents
FUND FEATURES HealthFund Amount $500 Individual $1,000 Employee + 1 Dependent $1,000 Employee + 2 Dependents $1,000 Family Amount contributed to the Fund by the employer Fund Coinsurance Percentage at
More informationImportant 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.uhs.wisc.edu/ship or by calling 1-866-796-7899. Important
More informationOverVIEW of Your Eligibility Class by determineing Benefits
OVERVIEW OF YOUR BENEFITS IMPORTANT PHONE NUMBERS Benefit Fund s Member Services Department (646) 473-9200 For answers to questions about your eligibility or prescription drug benefit. You can also visit
More information$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.
More informationHow To Pay For Health Care With A Health Care Plan With A Premium Rate Of $1,000 A Year
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 informationComparison of Health Care Plans Metro Interagency Insurance Program Effective Date: July 1, 2015
Comparison of Health Care Plans Metro Interagency Insurance Program Effective Date: July 1, 2015 Wellmark Blue Cross Blue Shield Customer Service: 1-800-277-8380 Participating Provider Directory Information:
More informationAdministered by Capital BlueCross 1
Administered by Capital BlueCross 1 PPO HRA Plan/Rx 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
More information: Blue Cross Blue Shield Silver 1, a Multi-State Plan
: Blue Cross Blue Shield Silver 1, a Multi-State Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/2014 12/31/14 Coverage for: Single Plan Type: EPO This
More informationImportant Questions Answers Why this Matters:
Anthem BlueCross BlueShield WI 2-99 Lumenos Health Savings Account POS Copay Option 4 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2014-11/30/2015 Coverage
More informationMedical 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 -
More informationAnthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60)
Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60) Summary of Benefits and Coverage: What this Plan Covers & What it Costs
More informationImportant Questions Answers Why this Matters: Referred providers $0 person/ $0 family; self-referred providers $2,500 person/ $5,000 family
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.thehealthplan.com or by calling 1-800-447-4000. Important
More informationBanner Health - Choice Plus Coverage Period: 1/1/2015-12/31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.bannerbenefits.com by clicking on the Resources tab and then Plan
More informationPhysicians Plus Insurance Corporation Coverage Period: 2015 Summary of Benefits and Coverage: WPE Traditional Uniform Benefits Plan Code: EHSTWWPE
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
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
Molina Healthcare of Ohio, Inc.: Molina Gold Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family ǀ Plan
More informationImportant 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 informationSenate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***
Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350
More informationWhat 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
More informationSt Olaf College Coverage Period: Beginning on or after 09-01-2014
St Olaf College Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage Period: Beginning on or after 09-01-2014 Coverage for: Single and family coverage Plan Type: PPO This is
More informationImportant Questions Answers Why this Matters: In-network: $0/Individual; $0/Family Out-of-network: $500/Individual; $1,000/Family
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 or by calling 1-800-445-7490. Important Questions
More informationThe Ohio State University: Basic PPO 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 hr.osu.edu/hrpubs/ben/medicalspd.pdf or by calling 614-292-1050
More informationPPO 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
More information