TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard
|
|
- Joshua Small
- 7 years ago
- Views:
Transcription
1
2 TRICARE Benefits Cost Chart View our Benefits A-Z page for benefit information. Important points to remember regarding copayments and cost-shares: Subject to change at the beginning of each year (October 1). Copayments are per occurrence or per visit. Point-of-service (POS) cost-shares and deductibles may apply to TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime TRICARE Standard including TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR) and TRICARE Young Adult (TYA) Standard, may be required to pay up to 15 percent above the TRICARE allowed amount when using a non-participating provider. TRICARE Standard (including TRS, TRR and TYA Standard) cost-shares are applied to outpatient services once the deductible is met. A copayment of $17.05 per day for hospitalization/inpatient care provided at a military treatment facility may apply. Cost Chart Active Duty Family Members Retired Service Members and Their Families TRICARE Prime/ TRICARE Prime Remote/TRICARE Young Adult Prime Allergy Services TRICARE Standard/TRICARE Reserve Select/TRICARE Young Adult Standard allowed TRICARE Prime/ TRICARE Young Adult Prime TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard Ambulance Services Ambulatory Surgery (same day) in an outpatient hospital or ambulatory surgery center (ASC) Ancillary Services (Cardiovascular studies, diagnostic radiology and pathology) allowed $20 copayment $25 copayment 2 no deductible $25 copayment 2 allowed Breast MRIs (Screening) 1 No cost-share, no deductible No cost-share, no deductible Breast MRIs (Diagnostic) allowed Cardiovascular Disease Screenings 1 (Includes cholesterol and blood pressure screenings) Non-network Provider: 20% of allowed
3 Chemotherapy/Radiation Treatments allowed Clinical Preventive Exams 1 No cost-share, no deductible No cost-share, no deductible Colonoscopies (Preventive) or other colon cancer screenings 1 No cost-share, no deductible No cost-share, no deductible Colonoscopy, Proctosigmoidoscopy and Flexible Sigmoidoscopy (Diagnostic) allowed Durable Medical Equipment allowed 20% of Emergency Room Services Eye Exams (Routine) 1 Eye Exams (Diagnostic) Genetic Testing 1 allowed allowed allowed allowed $30 copayment 2 Home Health Care 5 No cost-share, no deductible No cost-share, no deductible Home Infusion Therapy 5 No cost-share, no deductible No cost-share, no deductible Hospice Care 5 No cost-share, no deductible No cost-share, no deductible
4 Hospitalization for Medical/Surgical Care $11/day $17.05/day ($25 min charge) 2 ($25 min charge) 2 Network Provider: Lesser of $250/day or 25% of ; plus 20% of professional fees DRG 6 Non-network Provider: Lesser of $708/day or 25% of billed ; plus 25% of professional fees Hospitalization for Behavioral Health (Not including Partial Hospitalization Programs (PHP), Residential Treatment Centers or Substance Use Disorder Treatment) $20/day ($25 min charge) 2 $40/day 2 Non-network Provider: High Volume 3 Hospital: 25% of billed or Low Volume 3 Hospital: Lesser of $208/day or 25% of billed ; plus 25% of professional fees Immunizations 1 No cost-share, no deductible No cost-share, no deductible Infectious Disease Screening 1 allowed Laboratory Services allowed 4 Mammograms (Screening) 1 No cost-share, no deductible No cost-share, no deductible Mammograms (Diagnostic) allowed $11/day ($25 min Maternity Inpatient Services $17.05/day ($25 min charge) 2 charge) 2 Network Provider: Lesser of $250/day or 25% of ; plus 20% of professional fees DRG 6 Non-network Provider: Lesser of $708/day or 25% of billed ; plus 25% of professional fees Maternity outpatient care for delivery planned in a hospital No cost-share, no deductible
5 Maternity outpatient care for delivery planned at home or other setting Maternity outpatient care for delivery planned in TRICARE authorized birthing center Medical Supplies Medication Management (Behavioral health) allowed $25 copayment 2 $25 copayment 2 Occupational Therapy allowed allowed allowed allowed 20% of Pap Smears (Screening) 1 No cost-share, no deductible No cost-share, no deductible Pap Smears (Diagnostic) allowed Partial Hospitalization Programs (PHP) Physical Therapy $20/day ($25 min charge) 2 $40/day 2 ; plus 25% of professional fees allowed
6 Prosthetic Devices allowed 20% of Psychotherapy (Outpatient mental health) allowed Individual/Family Therapy: $25 Group Therapy: $17 Psychological Testing allowed Residential Treatment Center (RTC) $20/day ($25 min charge) 2 $40/day 2 School Physicals 1 allowed Skilled Nursing Facility (SNF) Care $17.05/day ($25 min charge) 2 charge) 2 $11/day ($25 min Network Provider: Lesser of $250/day or 20% of ; plus 20% of professional fees ; plus 25% of professional fees Speech Therapy Sleep Studies allowed allowed Network Provider: 20% of contracted rate
7 Cost Chart Active Duty Family Members Retired Service Members and Their Families TRICARE Prime/ TRICARE Prime Remote/TRICARE Young Adult Prime TRICARE Standard/TRICARE Reserve Select/TRICARE Young Adult Standard TRICARE Prime/ TRICARE Young Adult Prime TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard Substance Use Disorder Treatment $20/day ($25 min charge) 2 $40/day 2 Network Provider: 20% Non-network Provider: High Volume 3 Hospital: 25% of or Low Volume 3 Hospital: Lesser of $208/ day or 25% of billed ; plus 25% of professional fees. Urgent Care allowed Well-Child Care Visits 1 No cost-share, no deductible No cost-share, no deductible X-ray Services allowed 4 ¹ Clinical preventive services are screenings or treatment with no symptoms. See the Clinical Preventive Services page for coverage details. 2 The copayment is for facility fees, there is no separate copayment for professional fees. There may be an additional cost-share for separately billed durable medical equipment (DME) or prosthetics associated with a surgical procedure (e.g., implanted devices or braces). 3 High volume means the facility has discharged 25 or more TRICARE patients, under behavioral health, 25 or more TRICARE patients, under behavioral health, 877-TRICARE. 4 - pendent laboratory or radiology facility. 5 and hepatitis B vaccines, oral cancer drugs, antiemetic drugs, orthotics, prosthetics, enteral and parenteral nutritional therapy, and drugs/biologicals administered by other than oral methods are services that can be paid in addition to the prospective payment amount subject to applicable copayment/ cost-sharing and deductible amounts. 6 directly. Providers can contact 877-TRICARE. An Important Note about TRICARE Cost Information Changes to TRICARE programs are continually made as public law and/or federal regulation are amended. The preceding information is provided to help you better understand what Tricare items may have out-of-pocket expenses. For complete details contact your Tricare representative at TRICARE is a registered trade mark of TRICARE Management Activity. All rights reserved. PF0511x029x1211
8 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS While many Veterans qualify for free healthcare services based on a VA compensable service-connected condition or other qualifying factor, most Veterans are asked to complete an annual financial assessment, to determine if they qualify for free services. Veterans whose income exceeds the established VA Income Thresholds, as well as those who choose not to complete the financial assessment, must agree to pay required copays to become eligible for VA healthcare services. Copays Primary Care Services: $15 Specialty Care Services: $50 Prescriptions: 30-day or less supply for certain Veterans: $8 30-day or less supply for higher income Veterans: $9 There are two inpatient copay rates, the full rate and the reduced rate. Priority Group 7 and certain other Veterans are responsible for paying 20 percent of VA's inpatient copay rate. Inpatient Copay for the first 90 days of care during a 365-day period $ Inpatient Copay for each additional 90 days of care during a 365-day period $ Daily Charge.. $2/day Priority Group 8 and certain other Veterans are responsible for VA's full inpatient copay rate. Inpatient Copay for the first 90 days of care during a 365-day period.. $1,156 Inpatient Copay for each additional 90 days of care during a 365-day period.$578 Daily Charge. $10/day Veterans living in high cost areas may qualify for a reduced inpatient copay rate. For more information contact VA toll-free at VETS (8387). Long term care copays are based on three levels of care: Inpatient: Up to $97 per day (Community Living (Nursing home), Respite, Geriatric Evaluation) Outpatient: $15 per day (Adult Day Health Care, Respite, Geriatric Evaluation) Domiciliary: $5 per day Actual copay will vary based on Veteran s current financial assessment.
9 Some Veterans qualify for free healthcare and/or prescriptions based on special eligibility factors including but not limited to: Former Prisoner of War status 50% or more compensable VA service-connected disabilities (0-40% compensable serviceconnected may take copay test to determine prescription copay status) Veterans deemed catastrophically disabled by a VA provider Special registry examinations offered by VA to evaluate possible health risks associated with military service Counseling and care for military sexual trauma Compensation and Pension examinations Care that is part of a VA research project Care related to a VA-rated service-connected disability Readjustment counseling and related mental health services Care for cancer of head or neck caused by nose or throat radium treatments received while in the military Individual or Group Smoking Cessation or Weight Reduction services Publicly announced VA public health initiatives, for example, health fairs Care potentially related to combat service for Veterans that served in a theater of combat operations after November 11, 1998 Laboratory and electrocardiograms Hospice care The preceding information is provided to help you better understand what VA items may have out-of-pocket expenses. For complete details contact your VA representative at or visit their website at
CENTRAL 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 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 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 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 informationCOVERAGE SCHEDULE. The following symbols are used to identify Maximum Benefit Levels, Limitations, and Exclusions:
Exhibit D-3 HMO 1000 Coverage Schedule ROCKY MOUNTAIN HEALTH PLANS GOOD HEALTH HMO $1000 DEDUCTIBLE / 75 PLAN EVIDENCE OF COVERAGE LARGE GROUP Underwritten by Rocky Mountain Health Maintenance Organization,
More informationNational 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 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 information2016 Summary of Benefits
2016 Summary of Benefits Health Net Healthy Heart (HMO) Alameda and Stanislaus counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0171 CMS Accepted 09172015
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 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 information[2015] SUMMARY OF BENEFITS H1189_2015SB
[2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare
More informationSummary of Benefits Community Advantage (HMO)
Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
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 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 informationHNE Premier 1 (HMO) and HNE Premier 2 (HMO)
2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I
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 information2016 Summary of Benefits
2016 Summary of Benefits Health Net Violet Option 3 (PPO) Douglas and Josephine counties, OR Benefits effective January 1, 2016 H5520 Health Net Life Insurance Company H5520_2016_0202 CMS Accepted 09162015
More informationFIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)
FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties 1 P age SECTION I - INTRODUCTION TO SUMMARY
More informationSUMMARY OF BENEFITS. Cigna-HealthSpring Achieve (HMO SNP) H3949-024. January 1, 2016 - December 31, 2016. 2015 Cigna H3949_16_32723 Accepted
SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Achieve (HMO SNP) H3949-024 2015 Cigna H3949_16_32723 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives
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 informationPreauthorization Requirements * (as of January 1, 2016)
OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations
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 informationIndependent Health s Medicare Passport Advantage (PPO)
Independent Health s Medicare Passport Advantage (PPO) (a Medicare Advantage Preferred Provider Organization Option (PPO) offered by INDEPENDENT HEALTH BENEFITS CORPORATION with a Medicare contract) Summary
More information2015 Medicare Advantage Summary of Benefits
2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015
More informationJanuary 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1
January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we
More informationCovered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered.
Covered Benefits Services Abortions Allergy Testing Audiology Birth Control Services Blood & Blood Plasma Bone Mass Measurement (bone density) Case Management Chemotherapy Chiropractor Services (manipulation/subluxation)
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 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 informationSummary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)
Summary of Benefits January 1, 2016 December 31, 2016 FIRSTCAROLINACARE INSURANCE COMPANY FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties This booklet
More informationSummary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711)
Summary of s and January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE For more information about benefits or enrollment, call us or visit our website at www.martinspoint.org/medicare. 1-888-408-8285
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 informationAn ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits
An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits The chart below presents the list of benefits covered by Medicare, and
More information2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
More informationIN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)
HMO-OA-CNT-30-45-500-500D-13 HMO Open Access Contract Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations
More informationCDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO)
Introduction to the Summary of Benefits Report for CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO) January 1, 2015 December 31, 2015 CAPITAL, CENTRAL, SOUTHERN TIER,
More informationJanuary 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A
January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of
More informationJanuary 1, 2015 December 31, 2015
BLUESHIELD FOREVER BLUE MEDICARE PPO VALUE AND BLUESHIELD MEDICARE PPO 750 (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
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 informationAlternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services
Alternative Benefit Plan (ABP) ABP Cost-Sharing & Comparison to Standard Medicaid Services Most adults who qualify for the Medicaid category known as the Other Adult Group receive services under the New
More informationSummary of Benefits. Offered by. H5826_MA_194_2012_v_01_SB006 CMS Approved 08.24.2011
2012 Summary of Benefits Offered by H5826_MA_194_2012_v_01_SB006 CMS Approved 08.24.2011 Section I Introduction to the Summary of Benefits for Community HealthFirst MA Plan (HMO) January 1, 2012 - December
More informationSchedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016
Schedule of Benefits for the MoDOT/MSHP Medical Plan Medicare ASO PPO 20088 Effective 1/1/2016 This Schedule of Benefits summarizes your obligation towards the cost of certain covered services. Refer to
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 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 information2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
More information2015 Summary of Benefits
2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list
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 information2015 Summary of Benefits
2015 Summary of Benefits Value (HMO-POS) Essentials Rx (HMO-POS) (H4270) January 1, 2015 - December 31, 2015 Western Wisconsin (26 Counties) H4270_082914_1 CMS Accepted (09032014) SECTION I INTRODUCTION
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 informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits UPMC Consumer Advantage HSA PPO - Premium Network Primary Care Provider: 10% after Deductible Specialist: 10% after Deductible Deductible: $1,950 / $3,900 Rx: 10% after Deductible
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Ruby Select (HMO) Placer and Sacramento counties, CA Benefits effective January 1, 2015 H0562 Health Net of California, Inc. Material ID # H0562_2015_0285_B_CMS Accepted
More informationGroup Hospitalization and Medical Services, Inc.
Group Hospitalization and Medical, Inc. doing business as CareFirst BlueCross BlueShield [840 First Street, NE] [Washington, DC 20065] [202-479-8000] An independent licensee of the Blue Cross and Blue
More informationSCAN Health Plan. 2015 Summary of Benefits
SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8713_2014F File & Use Accepted 09032014 SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with
More informationNo Charge (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")
An Independent Licensee of the Blue Shield Association Custom Access+ HMO Plan Certificated & Management Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)
More information2015 Summary of Benefits
2015 Summary of Benefits January 1, 2015 December 31, 2015 Houston/Beaumont Area Y0067_PRE_H4506_SETX_SB41_0814 CMS Accepted 09/13/2014 HMO-SETX-SB K41 2015 Section I Introduction to Summary of Benefits
More informationof BenefitS Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted
agesummary of BenefitS Cover erage Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get
More informationJanuary 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Value Plan (HMO) H3312-060 H3312.060.1
January 1, 2016 December 31, 2016 Summary of Benefits H3312-060 H3312.060.1 Y0001_2016_H3312_060 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of
More informationIowa Wellness Plan Benefits Coverage List
Iowa Wellness Plan Benefits Coverage List Service Category Covered Duration, Scope, exclusions, and Limitations Excluded Coding 1. Ambulatory Services Primary Care Illness/injury Physician Services Should
More informationHow To Compare Your Medicare Benefits To Health Net Ruby Select (Hmo)
2015 Summary of Benefits Health Net Ruby Select (HMO) Maricopa and Pinal counties Benefits effective January 1, 2015 H0351 Health Net of Arizona, Inc. Material ID # H0351_2015_0258 CMS Accepted 08302014
More information$250 copay per admit. $250 copay per admit
BENEFIT IN- NETWORK OUT- OF- NETWORK Deductible NONE NONE Out- of- Pocket Maximum $6,350 Single/ $12,700 Family NONE HOSPITAL INPATIENT FACILITY - NON MATERNITY Medical/Surgical Skilled Nursing Facility
More informationSummary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015. HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595
Summary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015 HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595 For Medicare-eligible beneficiaries residing in Arenac, Bay,
More informationCounty of San Bernardino - Retiree Shield Signature High Option
An Independent Member of the Blue Shield Association County of San Bernardino - Retiree Shield Signature High Option Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California
More informationSCAN Health Plan. 2015 Summary of Benefits
SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8712_2014F File & Use Accepted 09032014 ( a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with a Medicare contract)
More informationTribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP
Tribute Health Plan of Oklahoma Tribute Health Plan of Oklahoma HMO SNP 2015 Summary of Benefits This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Healthy Heart (HMO) Placer and Sacramento counties, CA Benefits effective January 1, 2015 H0562 Health Net of California, Inc. Material ID # H0562_2015_0273 CMS Accepted
More informationEssentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare
Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 24 (HMO-POS). Next year, there will
More informationEssentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare
Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 25 (HMO-POS). Next year, there will
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 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 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 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 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 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 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 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 4X8 of Southern State Community College Enrolling Group Number: 755032
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 informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Group Medicare Advantage-Prescription Drug Plan for San Francisco Health Service System (SFHSS) January 1, 2016 to December 31, 2016 Blue Shield of California
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 informationSCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits. Y0057_SCAN_9240_2015F File & Use Accepted
SCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits Y0057_SCAN_9240_2015F File & Use Accepted SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health
More informationSub Health Insurance Option Food Service - New Hire Memo
MESQUITE ISD BENEFITS Sub Health Insurance Option Food Service - New Hire Memo Welcome to the Mesquite ISD family! If you are a new substitute, you must enroll in or decline medical coverage within 31
More informationHealthy Michigan MEMBER HANDBOOK
Healthy Michigan MEMBER HANDBOOK 2015 The new name for Healthy 1 TABLE OF CONTENTS WELCOME TO HARBOR HEALTH PLAN.... 2 Who Is Harbor Health Plan?... 3 How Do I Reach Member Services?... 3 Is There A Website?....
More informationUNITED TEACHER ASSOCIATES INSURANCE COMPANY P.O. Box 26580 Austin, Texas 78755-0580 (800) 880-8824
UNITED TEACHER ASSOCIATES INSURANCE COMPANY P.O. Box 26580 Austin, Texas 78755-0580 (800) 880-8824 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BASIC AND EXTENDED BASIC PLANS The Commissioner of
More informationINDIVIDUAL PLANS SOUTH CAROLINA OPEN ACCESS 1000
BENEFIT IN NETWORK OUT OF NETWORK This plan is intended to comply with the federal Patient Protection and Affordable Care Act. Provisions are subject to change as additional regulatory guidance becomes
More informationHEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC.
HEALTH SAVINGS PPO PLAN (WITH HSA) - COLUMBUS PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2016 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible
More informationSUMMARY OF BENEFITS 2016 EmblemHealth PPO I and EmblemHealth Advantage (PPO) Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester
SUMMARY OF BENEFITS 2016 and Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester January 1, 2016 December 31, 2016 H5528_125910 Accepted 9/13/2015 SECTION I - INTRODUCTION TO SUMMARY
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 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 informationSummary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma
Summary of Benefits 2016 HMO King, Pierce, Snohomish, Spokane and Thurston Counties premera.com/ma Plus Section 1 Introduction to the and Plus This booklet gives you a summary of what we cover and what
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 informationLegacy Health Medicare Advantage Plan
Legacy Health Medicare Advantage Plan Thank you for your interest in applying for the Legacy Health Medicare Advantage plan powered by Moda Health. Below are links to the items which are part of the Enrollment
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 informationJanuary 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Prime Plan (HMO) H3931-087 H3931.087.1
January 1, 2016 December 31, 2016 Summary of Benefits H3931-087 H3931.087.1 Y0001_2016_H3931_087 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of
More informationEffective January 1, 2014 through December 31, 2014
Summary of Benefits Effective January 1, 2014 through December 31, 2014 The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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 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 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 informationJanuary 1, 2016 December 31, 2016. Summary of Benefits. Coventry Medicare Advantage Total Care (HMO) H2672-009 H2672.009.1
January 1, 2016 December 31, 2016 Summary of Benefits H2672-009 H2672.009.1 Y0001_2016_H2672_009 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of
More informationBlue Shield 65 Plus Choice Plan (HMO) Blue Shield 65 Plus (HMO) summary of benefits
summary of benefits Los Angeles (partial) & Orange Counties January 1, 2015 to December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
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 informationHealth Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary
5 Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Plans Medicare members, by plan. Topics: Health
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 information