Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO Effective 1/1/2016
|
|
- Antony Heath
- 7 years ago
- Views:
Transcription
1 Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to your Plan Document for a detailed description of covered services and limitations or exclusions. *The Participant will be responsible for 100% of amounts above the Out-of-Network Rate. All services must be medically necessary as a condition of coverage and not otherwise limited or excluded. BENEFITS AND SERVICES 1. Annual Deductible MEDICARE ASSIGNED CLAIMS MEMBER RESPONSIBILITY MEDICARE NON-ASSIGNED CLAIMS MEDICARE NON-COVERED CLAIMS FOR SERVICES THAT THE PLAN COVERS IN-NETWORK OUT-OF-NETWORK Total amount a plan Participant is required to pay each calendar year before applicable coinsurance is applied to covered services. The Annual Deductible need only be met once per plan Participant per calendar year. Individual Medical $450 Private Duty Nursing $50 Individual Medical $450 Private Duty Nursing $50 Individual Medical $ Annual Out-of-Pocket Maximum (per Individual) The annual Out-of-Pocket Maximum need only be met once per Plan Participant per calendar year. $0 $0 $1,600 $2,425 The following applies to the Out-of- Pocket Maximum: Medical Coinsurance for Covered services and supplies Medical Deductible Medical Copayments The following does not apply to the Out-of-Pocket Maximum: Pharmacy Deductible Pharmacy Copayments Pharmacy Coinsurance Costs above the Out-of-Network Rate Non-Covered services and supplies Utilization review penalties Refer to the Plan Document for the complete definition of Out-of-Pocket Maximum. deductible. On Medicare non-assigned claims, members have Effective 1/1/
2 3. Maximum Lifetime Benefit Combined total of all Covered Benefit Unlimited Unlimited Unlimited Unlimited 4. Allergy Injections 1 2 Rate * 5. Cancer screenings Coverage includes non-preventive cancer screenings. Cancer screenings not coded as preventive shall include the screenings and office visits related to the screening Chiropractic Services Coverage is provided for manipulation and spinal X-ray services. Office visit not covered. 1 Limited to 30 manual manipulation of the spine treatments per calendar year and 1 spinal X-ray per calendar year after deductible 2 Limited to 30 manual manipulation of the spine treatments per calendar year and 1 spinal X-ray per calendar year 7. Contraceptives Certain services may be Covered under the Preventative Care Benefit. Refer to the Preventative Care section of Article 5 of the Summary Plan Document. up to age 55 years. After age 55 years, deductible, copays and coinsurance apply. Refer to the Birth Control section of Article 5 of the Summary Plan Document. deductible. On Medicare non-assigned claims, members have Effective 1/1/
3 8. Durable Medical Equipment and Diabetic Supplies Covered diabetic supplies include glucose monitors, test strips and lancets Emergency Ambulance Services Coverage is provided for Emergencies as defined in the Plan Document Emergency Care Services Coverage is provided for worldwide emergency health services as defined in the Plan Document. Copayment waived if accidental injury or patient is admitted. Participants may have no additional $75 Copayment then 1 If deemed Emergency Care: $75 Copayment then 10% Coinsurance of negotiated rate or billed charges after Deductible* If not deemed Emergency Care: $75 Copayment then 20% Coinsurance Deductible* 11. First Three Pints of Blood 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/
4 12. Hearing Aids and Screenings for Dependent children with developmental delays up to 26 years of age (including Cochlear Implants and Bone Anchored Hearing Aids) 1 Limited to 1 hearing aid per ear every 24 months. Limited to 1 diagnostic hearing screening and/or audiogram every 12 months. 13. Home Health Care and Hospice Immunizations Coverage is provided in accordance with the recommended schedules in Appendix B of Article 5. The Plan will Cover the Zoster (shingles) vaccine and administration for Participants fifty (50) years of age and older. after the Medicare of eligible expenses Shingles vaccine and administration is only Covered when received from a Participating Pharmacy. 15. Inpatient Hospital Services Unlimited coverage is provided for medically necessary physician and surgeon services, semi-private accommodations (unless a private room is the only room available or is required for medical reasons), operating rooms and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, special duty nursing as prescribed, short-term rehabilitation services, nursing care, meals and special diets. 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/
5 16. Maternity Care, Inpatient Hospital Coverage for subscriber and Dependent. Covered services include all physician services for mother and newborn(s), delivery, newborn nursery services and semi-private accommodations (unless a private room is the only room available or is required for medical reasons). 1 2 Coverage for newborns limited to 48 hours for a vaginal delivery or 96 hours for a cesarean section, unless eligible to enroll in Plan as a dependent. 17. Maternity Care Office Visits Coverage for subscriber and Dependent. Covered services include pre-natal and post-natal care, examinations, tests and educational services. (Infertility testing, office visit treatments and surgery are not covered.) Mental Health/Substance Abuse - Inpatient Mental Health/Substance Abuse - Outpatient Nutritional Counseling Coverage is provided for nutritional counseling as referenced in Nutritional Counseling section of the Summary Plan Document. deductible. On Medicare non-assigned claims, members have Effective 1/1/ $0 Copayment or 0% Coinsurance of eligible expenses
6 21. Office Visits Non-preventive care including diagnosis, consultation and telemedicine. 1 2 Preventive care office visits not covered 22. Orthotic Appliances and Prosthetic Devices Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to lab, radiology, and mammography. Certain procedures and tests are considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section. 1 2 services not Covered 24. Outpatient Surgery Benefits are provided for covered services rendered at an outpatient hospital or free standing surgery center. 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/
7 25. Services include immunizations as outlined in Article 5 of the Plan document and any service, procedure or office visit coded as preventive, including but not limited to preventive cancer screenings, routine health assessments, well-child care, and child health supervision services. If covered by Medicare, of eligible expenses of eligible expenses This is applied to routine or preventive services excluding dental, hearing and vision services. Cancer screenings not coded as preventive may be applied to deductible and coinsurance. Refer to the Cancer Screenings section. Refer to the Office Visits section. Shingles vaccine and administration is covered under Part D. 26. Prosthetics Devices and Orthotic Appliances Refer to the Orthotic Appliances and Prosthetic Devices section. 27. Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission. Coverage is provided for a semiprivate accommodations (unless a private room is the only room available or is required for medical reasons). 1 2 deductible. On Medicare non-assigned claims, members have Effective 1/1/
8 28. Therapy Rehabilitation Services and Supplies Coverage is provided for Medically Necessary Therapy Services as defied in Article Limited to a combined total of 60 physical, occupational, and speech therapy visits per calendar year for both in-network and out-of-network and is subject to applicable deductibles(s) and Coinsurance 2 Limited to a combined total of 60 physical, occupational, and speech therapy visits per calendar year for both innetwork and outof-network and is subject to applicable deductibles(s) and Coinsurance 29. Transplant Services Prior Authorization required. Contact the Claims Administrator s Transplant Case Manager for Transplant Benefits and Covered services. During the Case Rate Participant is responsible for Coinsurance equal to 0% of the case rate that is in effect at the time of service as agreed to by the Claims Administrator and the closest Designated Transplant Network Facility. Deductible does not apply. During the Case Rate Participant is responsible for: Coinsurance equal to 20% of the case rate that is in effect at the time of service as agreed to by the Claims Administrator and the closest Designated Transplant Network Facility After the case rate Participant is responsible for the Deductible then a Coinsurance equal to 10% of the approved amount for the services received. plus the difference between the case rate and the Non- Participating Provider payment schedule that is in effect at the time of service. Deductible does not apply. After the case rate Participant is responsible for the Deductible then a Coinsurance equal to 20% of the approved amount for the services received. deductible. On Medicare non-assigned claims, members have Effective 1/1/
9 30. Urgent Care Services Urgent Care Services (as deemed Urgent Care by the Claims Administrator) that are received at participating alternate facilities both in and out of the service area are Covered. Participants may have no additional 1 If deemed Urgent Care: 1 of negotiated rate or billed charges If not deemed Urgent Care: 2 of the Out-of- Network Rate * 31. Vision Services Services Refer to Vision Services section of Article 5 for Covered services. of Medicare allowed amount after deductible Participants may have no additional Payment 1 2 of the Out-of- Network Rate * deductible. On Medicare non-assigned claims, members have Effective 1/1/
National PPO 1000. PPO Schedule of Payments (Maryland Small Group)
PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer
More informationServices and supplies required by Health Care Reform Age and frequency guidelines apply to covered preventive care Not subject to deductible if PPO
Page 1 of 5 Individual Deductible Calendar year $400 COMBINED Individual / Family OOP Calendar year $4,800 Individual $12,700 per family UNLIMITED Annual Maximum July 1 st to June 30 th UNLIMITED UNLIMITED
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 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 informationCoventry Health & Life Insurance Company Small Group PPO Schedule of Benefits:
Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits: Plan ID#: Silver Traditional 3000 90-14 (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain
More informationAdditional Information Provided by Aetna Life Insurance Company
Additional Information Provided by Aetna Life Insurance Company Inquiry Procedure The plan of benefits described in the Booklet-Certificate is underwritten by: Aetna Life Insurance Company (Aetna) 151
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 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 informationLOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Calendar Year Out-of- Pocket Maximum Lifetime Maximum Per Individual Physician Office Visits Primary Care
More 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 informationPlans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan
Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined
More informationUNIVERSITY OF VIRGINIA HEALTH PLAN 2015 SCHEDULE OF BENEFITS CHOICE HEALTH
UNIVERSITY OF VIRGINIA HEALTH PLAN 2015 SCHEDULE OF BENEFITS CHOICE HEALTH SERVICES PROVIDED Direct Access through UVa Provider Network 1. PLAN COINSURANCE Applies to all expenses unless otherwise stated.
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 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 informationFEATURES NETWORK OUT-OF-NETWORK
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 3B Booklet Base: 3 For: Choice POS II - 950 Option - Retirees
More informationCIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna)
Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152 CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna) CERTIFICATE RIDER No CR7SI006-1 Policyholder:
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 informationCoventry Health and Life Insurance Company PPO Schedule of Benefits
State(s) of Issue: Oklahoma PPO Plan: OI08C30050 30 Coventry Health and Life Insurance Company PPO Schedule of Benefits Covered Services Contract Year Deductible For All Eligible Expenses (unless otherwise
More informationGreater Tompkins County Municipal Health Insurance Consortium
WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not
More informationDRAKE UNIVERSITY HEALTH PLAN
DRAKE UNIVERSITY HEALTH PLAN Effective Date: 1/1/2015 This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and the conditions specified in the
More informationPLAN DESIGN AND BENEFITS - New York Open Access EPO 1-10/10
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,
More information2015 Medical Plan Summary
2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is
More informationUnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits
UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits Please refer to your Provider Directory for listings of Participating Physicians, Hospitals, and other Providers.
More informationNew York Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010. PLAN DESIGN AND BENEFITS - NY Indemnity 1-10/10*
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $7,500 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services,
More informationIndependence Blue Cross Plan Summary PPO Core Medical Plan
TO: FROM: SUBJECT: MLH Medical Plan Participants MLH Human Resources Benefits Team Independence Blue Cross Plan Summary PPO Core Medical Plan Attached you will find the Independence Blue Cross (IBC) Plan
More informationCOMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES
COMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES Effective July 1, 2016 Medical/Vision/Pharmacy coverage is administered by PacificSource Health Plans Dental coverage is administered
More informationWhat is the overall deductible? Are there other deductibles for specific services?
Small Group Agility MS200 Coverage Period: Beginning on or after 01/01/2015 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
More informationAVMED POS PLAN. Allergy Injections No charge 30% co-insurance after deductible Allergy Skin Testing $30 per visit 30% co-insurance after deductible
AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific
More informationCalifornia Small Group MC Aetna Life Insurance Company
PLAN FEATURES Deductible (per calendar year) $1,000 per member $1,000 per member Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate
More informationBaltimore 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.
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 informationCoventry Health & Life Insurance Company
Coventry Health & Life Insurance Company (Benefits underwritten by Coventry Health & Life Insurance Company and Administered by Coventry Health Care of Missouri, Inc.) Small Group PPO Schedule of Benefits:
More informationHealth Plans Coverage Summary
www.hr.msu.edu/openenrollment Faculty & Staff Health Plans Coverage Summary PREVENTIVE SERVICES Health Maintenance Exam (1) Annual Gynecological Exam Pap Smear Screening (lab services only) Mammography
More informationPPO Insured Standard Network Deductible
BENEFIT HIGHLIGHTS Prepared for City of Seguin- Active BlueChoice Network This is a general summary of your benefits. Please refer to your Summary of and Coverage (SBC), or you may request a copy of the
More informationActive and Retiree Health Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309
Active and Retiree Health Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 1 PLAN INFORMATION... 2 BENEFIT CLASS
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 informationPARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
More informationNationwide Life Insurance Co.: University of Phoenix NJ Coverage Period: 9/24/13-8/23/14
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
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 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 informationDickinson Wright, PLLC 03956-006
Dickinson Wright, PLLC 03956-006 Flexible Blue SM Plan 3 Medical Coverage with Preventive Care and Mammography Benefits Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only
More informationThe Deductible is applicable to all covered services except for flat dollar Copayment services.
PRIORITY HEALTH www.priorityhealth.com/mpsers PRIORITYHMO SM PLUS PLAN MICHIGAN PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM (MPSERS) Effective January 1, 2016 through December 31, 2016 The HMO Plus plan
More informationCalifornia Small Group MC Aetna Life Insurance Company
PLAN FEATURES Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate separately
More informationCA Group Business 2-50 Employees
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Member Coinsurance Copay Maximum (per calendar year) Lifetime Maximum Referral Requirement PHYSICIAN SERVICES Primary
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 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 informationCovered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)
A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual
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 informationLEGACY PLAN Medical In-Ntwk Out-of-Ntwk
Preventive Services Age, gender and frequency criteria Adult physical/immunizations Well child visits/immunizations Screenings 0 Co-Insurance (after deductible) Out-of-Pocket Maximums Office Visit (copays)
More informationNATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS
WASHINGTON NATIONWIDE INSURANCE $20-40 / 250A NATIONAL MANAGED CARE SCHEDULE OF BENEFITS General Features Calendar Year Deductible Lifetime Benefit Maximum (Does not apply to Chemical Dependency) ($5,000.00
More informationState Health Plan: High Deductible Health Plan 50/50 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 http://www.shpnc.org and click on High Deductible Health
More informationPersonal Blue PPO QHDHP $5,000/$10,000
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 1-800-962-2242. Important
More informationBENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company
Appendix A BENEFIT PLAN Prepared Exclusively for The Dow Chemical Company What Your Plan Covers and How Benefits are Paid Choice POS II (MAP Plus Option 2 - High Deductible Health Plan (HDHP) with Prescription
More informationImportant 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
More informationUniversity of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance
University of Michigan Group: 007005187-0000, 0001 Comprehensive Major Medical (CMM) Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits.
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 informationPPO-Insured-Standard-with Network Deductible
B E N E F I T H I G H L I G H T S P r e p a r e d f o r T T U H S C - E L P A S O a n d O D E S S A B l u e C h o i c e N e t w o r k This is a general summary of your benefits. Please refer to your benefit
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 informationGroup Insurance Plan of Benefits for New York University (Control # 620610) administered by Aetna International Effective Date: January 1, 2016
Eligibility Provision Employee Regular full-time employees of New York University participating in this plan working a minimum of 25 hours per week. Dependent Wife or husband; same or opposite sex domestic
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 informationBates College Effective date: 01-01-2010 HMO - Maine PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC. - FULL RISK PLAN FEATURES
PLAN FEATURES Deductible (per calendar year) $500 Individual $1,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family
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 www.anthem.com or by calling 1-800-445-7490. Important Questions
More informationAlternate PPO/Alternate Rx
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 1-866-802-4761. Important
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 informationSUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015
SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective General Services In-Network Out-of-Network Primary care physician You pay $25 copay per visit Physician office
More informationSummary of Services and Cost Shares
Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits
More informationGreater Tompkins County Municipal Health Insurance Consortium
WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable
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 informationPLAN DESIGN AND BENEFITS Basic HMO Copay Plan 1-10
PLAN FEATURES Deductible (per calendar year) Member Coinsurance Not Applicable Not Applicable Out-of-Pocket Maximum $5,000 Individual (per calendar year) $10,000 Family Once the Family Out-of-Pocket Maximum
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 informationSchedule of Medical Benefits: State Participants 2015
I. Schedule of Medical Benefits Schedule of Medical Benefits: State Participants 2015 All benefits are paid according to the terms of the Master Contract between the Health Plan and Pharmacy Benefit Manager
More informationplease refer to our internet site, www.harvardpilgrim.org, or contact the Member Services
Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY PPO PLAN MAINE ID: MD0000000750_F2 X This Schedule of s summarizes your benefits under The HPHC Insurance Company PPO Plan (the Plan)
More informationMAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF BENEFITS
Fiscal Year 2015 2016 MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
More informationDelta College 007000338-0001, 0002, 0003, 0004, 0005, 0006, 0007 Community Blue SM PPO Medical Coverage Benefits-at-a-Glance
Delta College 007000338-0001, 0002, 0003, 0004, 0005, 0006, 0007 Community Blue SM PPO Medical Coverage 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 BlueCross BlueShield of Oregon: Preferred Coverage Period: 08/15/2015-08/14/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family
More informationSUMMARY!OF!BENEFITS!
SUMMARY!OF!BENEFITS!! BASIC!PLAN! COMPREHENSIVE! Policy Year Maximum Unlimited Unlimited Out-of-Pocket Limit OUTPATIENT!BENEFITS! Doctor s Visits Most Primary Care office visits at SHC are provided at
More informationReliability and predictable costs for individuals and families
INDIVIDUAL & FAMILY PLANS HEALTH NET HMO PLANS Reliability and predictable costs for individuals and families If you re looking for a health plan that s simple to use and easy to understand, you ve found
More informationPersonal Alliance 4500 Bronze ON
Personal Alliance 4500 Bronze ON Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual / Family Plan Type: HMO This is
More informationAPPENDIX C Description of CHIP Benefits
Inpatient General Acute and Inpatient Rehabilitation Hospital Unlimited. Includes: Hospital-provided physician services Semi-private room and board (or private if medically necessary as certified by attending)
More informationPLAN DESIGN AND BENEFITS HMO Open Access Plan 912
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $2,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services
More informationFlexible Blue SM Plan 2 Medical Coverage with Flexible Blue SM RX Prescription Drugs Benefits-at-a-Glance for Western Michigan Health Insurance Pool
Flexible Blue SM Plan 2 Medical Coverage with Flexible Blue SM RX Prescription Drugs Benefits-at-a-Glance for Western Michigan Health Insurance Pool The information in this document is based on BCBSM s
More informationBlue Cross of NEPA: Custom PPO Option 10014 Coverage Period: 03/01/2015-02/29/2016
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.bcnepa.com or by calling 1-888-345-2346. Important Questions
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 informationBenefit 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 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 informationUnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Health Savings Account (HSA) Plan 7PD of Educators Benefit Services, Inc. Enrolling Group Number: 717578
More informationUnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 7EG of Educators Benefit Services, Inc. Enrolling Group Number: 717578 Effective Date: January 1, 2012
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 www.gpatpa.com or by calling 915-887-3420. Important Questions
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://www.cs.ny.gov/employee-benefits or by calling 1-877-7-NYSHIP
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 informationPace University CIGNA Medical Detailed Benefit Summaries July 1, 2015 - June 30, 2016
Consumer Core HDHP In Net $50 (ONLY APPLICABLE TO THOSE Network Core $25 ALREADY ENROLLED) Network Choice Fund In Network In Network In Network Deductible $1,300/$2,600 (Cumulative) N/A N/A Coinsurance
More informationSMALL GROUP PLAN DESIGN AND BENEFITS OPEN CHOICE OUT-OF-STATE PPO PLAN - $1,000
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year; applies to all covered services) $1,000 Individual $3,000 Family $2,000 Individual $6,000 Family Plan Coinsurance ** 80% 60%
More informationCSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary
CSAC/EIA Health Small Group Access+ HMO 15-0 Inpatient Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
More informationImportant Questions Answers Why this Matters:
Student Employee Health Plan: NYS Health Insurance Program Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family
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 informationSUMMARY OF BENEFITS. Out-of-Network Care: $10,000 per policy year
OUTPATIENT BENEFITS Most Primary Care office visits at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the
More informationResourcing Christian Education International Policy # 06100A Benefits at a Glance Effective Date August 1, 2013
Resourcing Christian Education International is offering Medical, Vision, Pharmacy, and Medical Evacuation and Repatriation benefits through Cigna Global Health Benefits to our employees. This comprehensive
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 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 www.alaskacare.gov or by calling 1-800-821-2251. Important
More information