Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs
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- Lily Newton
- 6 years ago
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1 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 Important Questions Answers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? $3,000/family Network $6,000/family Non-Network Doesn't apply to coinsurance and network preventive care No Yes, $6,000/family Network $12,000/family Non-Network You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out-of-pocket limit? Is there an overall annual limit on what the insurer pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? Premiums, balance-billed charges and health care this plan doesn't cover. No Yes, See MedMutual.com/SBC or call for list of participating providers. No Yes Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Page 1 of 9
2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Limitations and Exceptions Network Provider Non-Network Provider Primary care visit to treat an injury or 10% coinsurance 40% coinsurance none If you visit a health care illness provider's office or clinic Specialist visit 10% coinsurance 40% coinsurance none Other practitioner office visit 10% coinsurance 40% coinsurance (15 visits per benefit period) (Chiropractic) Other practitioner office visit Not Covered Excluded Service (Acupuncture) Preventive care/ screening/ No charge Not Covered none immunization If you have a test Diagnostic test (x-ray) 10% coinsurance 40% coinsurance none Diagnostic test (blood work) 10% coinsurance 40% coinsurance none Imaging (CT/PET scans, MRIs) 10% coinsurance 40% coinsurance none Page 2 of 9
3 Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Limitations and Exceptions Network Provider Non-Network Provider If you need drugs to treat Generic drugs (Tier 1) 10% coinsurance 40% coinsurance Retail 30 days your illness or condition Mail Order 90 days For more information about prescription drug coverage, call or visit Preferred brand drugs (i.e. those drugs on the formulary Tier 2) 10% coinsurance 40% coinsurance Retail 30 days Mail Order 90 days Non-preferred brand drugs (Tier 3) 10% coinsurance 40% coinsurance Retail 30 days Mail Order 90 days Miscellaneous or Life-Style drugs (Tier 4) 10% coinsurance 40% coinsurance Retail 30 days Specialty drugs For injectable drugs to treat multiple sclerosis, cancer, etc. contact Caremark to learn if the drug is preferred or non-preferred Not all prescriptions are covered and some may be subject to prior approval. Contact Caremark for details. Page 3 of 9
4 Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Limitations and Exceptions Network Provider Non-Network Provider If you have outpatient Facility fee (e.g., ambulatory surgery 10% coinsurance 40% coinsurance none surgery center) Physician/surgeon fees (Outpatient) 10% coinsurance 40% coinsurance none Emergency room services 10% coinsurance none If you need immediate Emergency medical transportation 10% coinsurance none medical attention Urgent care 10% coinsurance 40% coinsurance none If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 40% coinsurance none If you have mental health, behavioral health, or substance abuse needs Physician/ surgeon fee (inpatient) 10% coinsurance 40% coinsurance none Mental/Behavioral health outpatient Benefits paid based on corresponding medical benefits none services Mental/Behavioral health inpatient Benefits paid based on corresponding medical benefits none services Substance use disorder outpatient Benefits paid based on corresponding medical benefits none services (alcoholism) Substance use disorder outpatient Benefits paid based on corresponding medical benefits none services (drug use) Substance use disorder inpatient Benefits paid based on corresponding medical benefits none services (alcoholism) Substance use disorder inpatient Benefits paid based on corresponding medical benefits none services (drug use) If you are pregnant Prenatal and postnatal care 10% coinsurance 40% coinsurance (Prenatal Visits are covered at no charge with in-network providers) Delivery and all inpatient services 10% coinsurance 40% coinsurance none Page 4 of 9
5 Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Limitations and Exceptions Network Provider Non-Network Provider Home health care 10% coinsurance 40% coinsurance none If you need help recovering or have other special health Rehabilitation services (Physical 10% coinsurance 40% coinsurance (30 visits per benefit period, needs Therapy) combined with Occupational If your child needs dental or eye care Therapy) 10% coinsurance 40% coinsurance (30 visits per benefit period, combined with Physical Therapy) 10% coinsurance 40% coinsurance (20 visits per benefit period) Habilitation services (Occupational Therapy) Habilitation services (Speech Therapy) Skilled nursing care 10% coinsurance 40% coinsurance none Durable medical equipment 10% coinsurance 40% coinsurance none Hospice service 10% coinsurance 40% coinsurance none Eye exam (Child) No charge Not Covered none Glasses Not Covered Excluded Service Dental check-up (Child) Not Covered Excluded Service Page 5 of 9
6 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic Surgery Dental check-up (Child) Dental Care (Adult) Glasses Hearing Aids Infertility Treatment Long-Term Care Routine Eye Care (Adult) Routine Foot Care Weight Loss Programs Note: Not all prescription drugs are covered. To learn if a specific drug is covered, call Caremark at Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric Surgery Non-emergency care when traveling outside the Private-Duty Nursing Chiropractic Care U.S. Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at X61565 or Page 6 of 9
7 Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: the plan at Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides To see examples of how this plan might cover costs for sample medical situations, see the next page Page 7 of 9
8 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan Pays $3,940 Patient Pays $3,600 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient Pays: Deductibles $3,000 Copays $0 Coinsurance $400 Limits or exclusions $200 Total $3,600 These numbers assume that the patient does not use an HRA or FSA. If you participate in an HRA or FSA and use it to pay for out-of-pocket expenses, then your costs may be lower. For more information about your HRA or FSA, please contact your employer group. Managing Type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan Pays $1,600 Patient Pays $3,800 Sample care cost: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedure $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient Pays: Deductibles $900 Copays $0 Coinsurance $0 Limits or exclusions $2,900 Total $3,800 Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: Page 8 of 9
9 Coverage Examples Questions and answers about Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. Patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments,and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summaries of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box on each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Page 9 of 9
Board of Huron County Commissioners : BASIC
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
Gundersen Health Plan: MN NJ Silver $2000-0% 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.gundersenhealthplan.org or by calling 1-800-897-1923.
St 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
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
Important Questions Answers Why this Matters: Network: $500 Individual / $1,500 Family;
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Important Questions Answers Why this Matters: What is the overall deductible?
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Coverage for: Group Plan Type: HMO. Important Questions Answers Why this Matters: What is the overall deductible?
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Important Questions Answers Why this Matters:
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Individual Plan: Silver 1 93-95 Coverage Period: 01/01/2014-12/31/2014
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What 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
Important Questions Answers Why this Matters: $3,000/ person $6,000/family Benefits not subject to deductible include: preventive care.
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 by calling 1-888-990-5702. Important Questions Answers Why this
Manhattan School of Music: BCS Insurance Company Coverage Period: 8/27/2014-8/27/2015 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 www.cirstudenthealth.com/msmnyc or by calling 1-800-322-9901.
Vantage Health Plan, Inc:
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.vantagehealthplan.com or by calling 1-888-823-1910. Important
CA Short Term Counseling: Cigna Health and Life Insurance Co Coverage Period: 01/01/2013-12/31/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://apps.cignabehavioral.com/web/acref/pmrscontroller?cat=initial
Medical Insurance - 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.loomisco.com or by calling 1-800-346-1223. Important
Primary Select Platinum Plan: Health Republic Insurance of New York Coverage Period: 01/01/2015 12/31/2015
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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
You can see the specialist you choose without permission from this 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.[insert] or by calling 1-800-[insert]. Important Questions
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.boonchapman.com or by calling 1-800-252-9653. Important
Important Questions Answers Why this Matters:
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LGC 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
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 by calling 1-888-990-5702. Important Questions Answers Why this
Maricopa Country Medical Society: Medical Plan Coverage Period: 1/1/2013 12/31/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mcmsbenefits.com or by calling 1-855-321-3167. Important
TotalFreedom 20/80 Platinum Plan: Health Republic Insurance of New York Coverage Period: 4/1/15 12/31/15 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 by calling 1-888-990-5702. Important Questions Answers Why this
2015 WPEG Coinsurance Plan Coverage Period: 1/1/2015-12/31/2015
2015 WPEG Coinsurance Plan Coverage Period: 1/1/2015-12/31/2015 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
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 austintexas.gov/benefits or by calling 512-974-3284. Important
Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses?
Yale Health Plan: Faculty, Managerial & Professional, Post-doctoral Associates and Fellows Coverage Period: 1/1/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage
HPN Solutions HMO 15 V2 $7/35/55
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.myhpnonline.com or by calling (702) 242-7300 or 1-800-777-1840.
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.iees.com or by calling 1-866-433-7462. Important Questions
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
: VIVA HEALTH Access 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
Not applicable because there s no out-of-pocket limit on your expenses. You can see the specialist you choose without permission from this 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.njcf.org or by calling 1-800-624-3096. Important Questions
How Much Does Your Health Care Plan Cover?
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.arml.org\benefit_programs.html or by calling 1-501-978-6137.
Are there services this Yes. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan
: SAIF Corporation All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest Coverage Period: January 1, 2016-December 31, 2016 Summary of Benefits and Coverage: What this Plan
Student Health Insurance Plan Insurance Company Coverage Period: 07/01/2015-06/30/2016
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.
TotalIndependence Silver Plan: Health Republic Insurance of New York Coverage Period: 01/01/2015 12/31/2015 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 by calling 1-888-990-5702. Important Questions Answers Why this
Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO
Massachusetts The HPHC Insurance Company PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO This
Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO
Massachusetts The HPHC Insurance Company PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO This
National Guardian Life Insurance Company: Kenyon College Student Health Insurance Plan Coverage Period: 08/15/2015-08/15/2016
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.
Town of Auburn: Fallon Select Care Network
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.fallonhealth.org. or by calling 1-800-868-5200. Important
Aetna HMO 1525 Local Government Active Private Rx
Important Questions 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
Important Questions Answers Why this Matters: In-network: $2,000 Single / $4,000 Family Out-of-network: $3,000 Single / $6,000 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.independenthealth.com or by calling 1-800-501-3439. Important
P.PCHP.250.95.15 (Platinum)
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 PreferredOne.com or by calling 763.847.4488 / 800.379.7727.
Luther College Health Care Plan: Luther College Coverage Period: January 1, 2015 December 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. Important Questions Answers Why this Matters: What is the overall
You can see the specialist you choose without permission from this 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.pekininsurance.com or by calling 1-800-322-0160. Important
You can see the specialist you choose without permission from this plan.
: Blue Option / Gold 800 Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family Plan Type: EPO This is only a summary.
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.
Health Alliance Plan. Coverage Period: 01/01/2015-12/31/2015. document at www.hap.org or by calling 1-800-422-4641.
Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual+Family Plan Type: HMO This is only a summary.
What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your medical/vision coverage and costs, you can get the complete terms in the policy or plan document at www.mycigna.com, by calling 1-800-Cigna24,
: Western University of Health Sciences (Oregon)
: Western University of Health Sciences (Oregon) All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest Coverage Period: March 1, 2015-February 29, 2016 Summary of Benefits
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 by calling 1-888-990-5702. Important Questions Answers Why this
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 by calling 1-888-990-5702. Important Questions Answers Why this
GREATER HOUSTON RETAILERS: Plan 1 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 plan document at www.assurantselffunded.com or by calling 1-888-292-0272. Important
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.cirstudenthealth.com/udmercy or by calling 1-800-322-9901.
Even though you pay these expenses, they don t count toward the out-ofpocket limit.
Commonwealth of Virginia: COVA Care Basic Coverage Period: 07/01/2014 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This
Massachusetts. Coverage Period: 1/1/2015 12/31/2015
Massachusetts The Harvard Pilgrim Hospital Prefer Best Buy Tiered Copayment HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/2015 12/31/2015 Coverage for:
MNHG: Fallon Select Care Network
MNHG: Fallon Select Care 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.fchp.org. or by calling 1-800-868-5200.
Massachusetts. The HPHC Insurance Company Best Buy Tiered Copayment ChoiceNet PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts
Massachusetts The HPHC Insurance Company Best Buy Tiered Copayment ChoiceNet PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 07/01/2015 06/30/2016 Coverage for: Individual
National Guardian Life Insurance Company Maine College of Art Student Health Insurance Plan Coverage Period: 09/01/2015-08/31/2016
J3A59 National Guardian Life Insurance Company 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
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.studentplanscenter.com or by calling 1-800-756-3702.
Health CO-OP Oregon Standard Silver Plan: Oregon s Health CO-OP Coverage Period: 1/1/2014-12/31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://ohcoop.org/benefits-and-coverage or by calling 1-855-722-8207.
Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Massachusetts HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual
Massachusetts. The Harvard Pilgrim Tiered Copayment HMO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts
The Harvard Pilgrim Tiered Copayment HMO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Massachusetts Coverage Period: 07/01/2015 06/30/2016 Coverage for: Individual + Family Plan Type:
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.peoplenotprofits.com or by calling 1-888-990-6635.
MNHG: Fallon Select Care Network
MNHG: Fallon Select Care 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.fallonhealth.org. or by calling
$1,900 individual / $3,800 family. Does not apply to preventive care and prescription drugs. 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.paramount insurancecompany.com or by calling 1-800-462-3589
Physicians 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
Massachusetts. The Harvard Pilgrim Best Buy HSA PPO. Coverage Period: 1/1/2015 12/31/2015
Massachusetts The Harvard Pilgrim Best Buy HSA PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/2015 12/31/2015 Coverage for: Individual + Family Plan Type:
You can see the specialist you choose without permission from this 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.pekininsurance.com or by calling 1-800-371-9622. Important
Administered 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
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 plan document at www.ctww.org or by calling 1-800-552-0635. Important Questions Answers
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
Massachusetts. Coverage Period: 7/1/2013 6/30/2014 Coverage for: Individual + Family Plan Type: HMO
Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 7/1/2013
$0 See the chart starting on page 2 for your costs for services this plan covers.
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/ca/lausd or by calling 1-800-700-3739. Important
HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015
HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: HMO This is only
Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs
HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual
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 document by calling 1-888-990-5702. Important Questions Answers Why this
Massachusetts. Coverage Period: 07/01/2014 06/30/2015 Coverage for: Individual + Family Plan Type: HMO
Massachusetts Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO-WSHG Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:
You can see the specialist you choose without permission from this 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.wmimutual.com or by calling 1-800-748-5340. Important
Health 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.
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,
Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts
Massachusetts The Harvard Pilgrim Best Buy HMO Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage for: Individual + Family Plan Type: HMO This
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
Ambetter Balanced Care 2 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 http://ambetter.sunshinehealth.com/ or by calling 877-687-1169,
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.
The Harvard Pilgrim/HPHC Insurance Company POS Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts
Massachusetts The Harvard Pilgrim/HPHC Insurance Company POS Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 01/01/2016 12/31/2016 Coverage for: Individual + Family Plan
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
Massachusetts. Coverage Period: 01/01/2013 12/31/2013 Coverage for: Individual + Family Plan Type: HMO
Massachusetts Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013 12/31/2013 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
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.kaiserpermanente.org or by calling 1-800-464-4000. Important
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
Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016
Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual
BlueSelect 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
Silver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014
Silver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan
Personal Plans Health Choice 2000: GuideStone Coverage Period: 01/01/2013 12/31/2013 Summary of Benefits and Coverage:
Personal Plans Health Choice 2000: GuideStone Coverage Period: 01/01/2013 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO
Cherokee Insurance High Deductible Plan 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 by calling 1-800-201-0450 Important Questions Answers Why this
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.
Coverage for: Individual 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.chpstudent.com or by calling 1-800-633-7867. Important
Nationwide Life Insurance Company: Ochsner Clinical School Coverage Period: 1/1/15 12/31/15
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.chpstudent.com or by calling 1-800-633-7867. Important