Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
|
|
- Berenice Francis
- 5 years ago
- Views:
Transcription
1 BluePoint 3 Benefit Time Period: 06/01/ /31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services that Apply to Deductible Deductible Aggregation - Single and Family Deductible Aggregation - In Network and Out of Network Medical Only Individual In Network & Out of Network aggregate together Deductible Carryover Months History Credit Coinsurance 0% Annual Out of Pocket Maximum - Single $4,425 $4,425 Annual Out of Pocket Maximum - Two Person $8,845 $8,845 Out-of-pocket maximums accumulate the coinsurance amount, medical copays, and include the deductible, if applicable. Annual Out of Pocket Maximum - Family $8,845 $8,845 Services that Apply to Out of Pocket Maximum Annual Out of Pocket Maximum Aggregation - Single and Family Annual Out of Pocket Maximum Aggregation - In Network and Out of Network Medical Only Individual In Network & Out of Network aggregate together Office Visit Cost Shares Cost Share - Primary Care $15 Cost Share - Specialist $15 Plan Limits Limits Aggregation - In-network and Out of Network In Network & Out of Network aggregate together Annual Maximum Lifetime Benefit Maximum Unlimited Unlimited 1 of /24/ :15:26
2 Kids Copay Age Limit Kids Copay Age Applies To Kids Copay Network Referrals Required Does t Apply Does t Apply ne Employer Deductible Funding Percentage 0% HSA vs HRA Plan/Calendar Year Coordination of Benefits Prior Authorization PreCertification PreCertification Penalty Does t Apply Calendar Year Benefits Made Whole Applies Does t Apply Does t Apply Who is Type of Tiers Dependent Coverage Dependent Age End Period Domestic Partner Coverage 2 Tier (EE / FAM) Age to which all dependents (excluding spouse) are covered Dependent To Age 26 Age to which all dependents (excluding spouse) are covered End of Month Additional Group Characteristics Total Employees Total Eligible Group Size Funding Arrangement Retiree Only Sovereign Nation Religious Group Grandfathered ASC 2 of /24/ :15:26
3 Inpatient Services Inpatient Facility Inpatient Hospital Services in Mental Health Care in 30 Days per year Mental Health Residential Care in 30 Days per year Substance Use Detoxification in 7 Days per year Substance Use Rehabilitation Substance Use Residential Care Skilled Nursing Facility in 45 Days per year Physical Rehabilitation in 60 Days per year Maternity Care in Routine Newborn Nursery Care in Prosthetic - Implanted Devices in Subject to 20% when not rendered in an inpatient setting Mastectomy in Observation Stay in Inpatient Professional Services Inpatient Hospital Surgery Anesthesia In Hospital Physician Visits and Consults Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care $15 Preadmission Pre-Operative Testing in Diagnostic X-ray in Routine X-ray in Advanced Imaging Services in Diagnostic Laboratory and Pathology in Routine Laboratory and Pathology in 3 of /24/ :15:26
4 Diagnostic Testing in Radiation Therapy $15 Chemotherapy $15 Infusion Therapy Inclusive of Primary Service Is inclusive in the Home Care Benefit and not covered as a separate benefit. Dialysis $15 Injectable Drugs Inclusive of Primary Service Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. Mental Health Care $15 20 Visits per calendar year Substance Use Care $15 Autism Applied Behavior Analysis Substance Use Family Counseling $15 This benefit is included in the 60 visits per year for Substance Use Care. Pulmonary Rehabilitation $15 Cardiac Rehabilitation $15 Home and Hospice Care Home Care Home Care in Hospice Care Hospice Care Inpatient in 210 Days Per Lifetime Hospice Care Outpatient in 210 Days Per Lifetime Family Bereavement in 5 Visits per year Outpatient and Office Professional Services Professional Services Outpatient Hospital and Ambulatory Surgery Office Surgery Diagnostic X-ray Routine X-ray 4 of /24/ :15:26
5 Advanced Imaging Services Diagnostic Laboratory and Pathology Routine Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Injectable Drugs Mental Health Care Substance Use Treatment Maternity Care Autism Applied Behavior Analysis Additional Surgical Opinion Second Medical Opinion for Cancer Pulmonary Rehabilitation Office Visits - Diagnostic Medications Administered in Office Eye Exams Diagnostic Hearing Evaluations Diagnostic Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine Adult Hearing Aids PCP / Specialist - Inclusive of Primary Service PCP / Specialist - Inclusive of Primary Service PCP / Specialist - t PCP / Specialist - t PCP / Specialist - t Is inclusive in the Home Care benefit and not covered as a separate benefit. Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. 20 Visits per Calendar Year 60 visit max per calendar year $15 for initial visit, remainder in Pediatric Hearing Aid Age Limit Does t Apply Pediatric Hearing Aids Cochlear Implants PCP / Specialist - t Subject to 20% when not rendered in an inpatient setting 5 of /24/ :15:26
6 Rehab and Habilitation Outpatient Facility Physical Rehabilitation $15 Occupational Rehabilitation $15 Speech Rehabilitation $15 Physical Habilitation $15 Occupational Habilitation $15 Speech Habilitation $15 Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation Physical Habilitation Occupational Habilitation Speech Habilitation Preventive Services Outpatient Facility and Professional Provider Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Cervical Cytology Preventative in 1 Exam per year includes associated labs and x-rays and appropriate routine immunizations 6 of /24/ :15:26
7 Prostate Cancer Screenings Mammography Preventive Facility in Mammography Preventive Professional Bone Density Testing Facility in Bone Density Testing Professional Colonoscopy Screening Facility in Colonoscopy Screening Professional Family Planning Pre/Post-Natal Care All Routine in. Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Education Diabetic Equipment Autism Assistive Communication Device Autologous Blood Banking Durable Medical Equipment (DME) Mastectomy Prosthesis Orthotics Foot Orthotics Prosthetic - External Benefit Prosthetic - Wigs External Benefit Medical Supplies Acupuncture Private Duty Nursing PCP / Specialist - t PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - 20% Coinsurance PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - t 20% or $15, whichever is Less 20% or $15, whichever is Less 7 of /24/ :15:26
8 Diagnoses Accidental Dental PCP / Specialist - Included Dental Oral Surgery PCP / Specialist - Included Temporomandibular Joint (TMJ) PCP / Specialist - t Nutritional Counseling PCP / Specialist - Included Nutritional Counseling is covered in full Inherited Metabolic Disorder - PKU PCP / Specialist - Included Infertility Care PCP / Specialist - Included Organ and Bone Marrow Transplants PCP / Specialist - Included Elective Sterilization PCP / Specialist - Included Interruption of Pregnancy PCP / Specialist - Included Custom Professional Smoking Cessation Emergency Services ER Facility OP Facility Emergency Room Visit $50 $50 ER Professional Physician Emergency Room Visit in Transportation Prehospital Emergency Services Transportation in in Air Ambulance Water Ambulance Urgent Care Facility Urgent Care Center Facility Visit $50 8 of /24/ :15:26
9 Urgent Care Professional Physician Urgent Care Center Visit Physician Office Visit for Urgent Care Total Health Management Programs Medical Management Services Case Management Program Case Management Behavioral Health Program Disease Management Program Health Promotion Incentive Programs Benefit Name Applies Additional Information Gym Membership Reimbursement Exercise Rewards HealthyRewards/ActiveRewards BlueHealthyDollars/UniveraFit Dollars Blue4U Other Incentive Plan Earn up to $600 per family per contract year for fitness facility memberships in this offline program by tracking 50 visits in a 6-month period. The program also includes free online tools to help in meeting wellness goals. Vision and Dental Vision Adult Eye Exams - Routine $15 1 Exam every 2 years Adult Eyewear - Routine Pediatric Vision Age Limit Does t Apply Pediatric Eye Exams - Routine $15 1 Exam every 2 years Pediatric Eyewear - Routine 9 of /24/ :15:26
10 Dental Adult Dental Pediatric Dental Age Limit 19 Pediatric Dental - Emergency Care Pediatric Dental - Preventive $15 Periodic exams, x-rays, cleanings, fluoride treatments. and sealants - Children up to age 19 Pediatric Dental - Routine Pediatric Dental - Endodontic Pediatric Dental - Prosthodontics Pediatric Dental - Orthodontics Exclusions Exclusions Benefit Name Convalescent and Custodial Care Cosmetic Services Dental Services Experimental or Investigational Treatment Felony Participation Government Facility Medicare or Other Governmental Program Military Service -Fault Automobile Insurance Services t Listed Services with Charge War Workers Compensation Excluded Rx Benefits Rx Plan Rx Plan DRUG COVERAGE EXCLUDED 10 of /24/ :15:26
11 Rx Benefits $0 Generics for Kids Generics for Kids Age Limit MAC Penalty Step Therapy Prior Authorization Oral Contraceptives Mandatory MO for Maintenance Drugs Days Supply Per Retail Order Days Supply Per Mail Order Copays Per Mail Order Supply Deductible Family Deductible Deductible applies to Embedded Rx Annual benefit maximum Benefit maximum applies to OOP Maximum OOP Maximum Applies to Does not apply Subject to Deductible Subject to Deductible The group has reviewed the benefit grid and accepts the benefits as indicated. Signature of Group Administrator: Date: This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by theterms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 11 of /24/ :15:26
Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible
Excellus BluePPO $5/$45/$90 Integrated Rx Benefit Time Period: 01/01/2019-12/31/2019 Thompson Health General Cost Sharing Expenses Deductible - Single $1,350 $1,350 $2,700 Deductible - Family $2,700 $2,700
More informationExcellus BluePPO Signature Hybrid 5
Excellus BluePPO Signature Hybrid 5 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse Essential General Cost Sharing Expenses - Single Domestic - $1,000 $2,500
More informationExcellus BluePPO Signature Deduct 3
Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single Domestic - $1,300 $2,500 $3,500
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
Excellus BluePPO Benefit Time Period: 01/01/2016-12/31/2016 COLGATE UNIVERSITY Cost Sharing Expenses Deductible - Single $250 $750 Deductible - Family $750 $2,250 0% 30% Annual Out of Pocket Maximum -
More informationMVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange
COST-SHARING Deductible Individual Family Prescription Drug Deductible Individual Family Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) Specialist Visits (or Home
More informationMetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold
SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency
More information2016 Rochester Regional Health PPO Medical Plan Summary
Out of Annual Deductible Annual Deductible includes co-pays, coinsurance. The amounts are combined across all s. None Single Two-Person EE + Children Family $1,800 $3,600 $5,400 $5,400 Annual Out of Pocket
More information2018 Anthem Blue Cross HMO*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage 100.00% Precertification Requirements Pre-certification is required for certain services. However, this is an
More information2018 Anthem Blue Cross Senior Secure HMO - Southern CA - Post 65 (Medicare Eligible)*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Prior authorization is required for select services. Services must be coordinated
More informationNew York Essential Plan cost-sharing matrix
New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program. The Plan is a health benefit
More informationBaltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017
HOSPITAL INPATIENT SERVICES Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017 About this chart: This chart is to be used as a guide only and does not contain
More informationNEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF BENEFITS SUPREME BENEFITS
BENEFIT GUIDE NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF SUPREME IN NETWORK FEATURES Primary Care Physician Not Required 2 Physician Referrals Not Required 2 Out of
More informationMEDICAL SCHEDULE OF BENEFITS
MEDICAL SCHEDULE OF BENEFITS Plan(s) 011 (F) All health benefits shown on this Schedule of Benefits are subject to the following: Lifetime and annual maximums, Deductibles, Co-pays, Plan Participation
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/HSA Plan EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK OUT-OF-NETWORK CATEGORY
More informationHealthyBlue Living SM
Deductible, Copays and Dollar Maximums Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all
More information*** NOTE *** ALL services subject to deductible, unless otherwise noted.
MEDICAL BENEFITS Fund Name: International Association of Machinists Motor City Revised: 3/14/18 MP Fund ID: 2800 SPD Version: 10/2004 Who is covered? Actives, Retirees, & their Dependents Tax ID: 38-1422403
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 BRONZE RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address Remit claims to: Gilsbar, Inc., P.O. Box 2947, Covington,
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK
More information2018 HDHP. Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network
2018 HDHP Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network HighPoint Denver Cofinity Network Out of Network Deductible
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
1 Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. BlueCross
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 PPO PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: CIGNA Physicians & Hospitals
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 SILVER RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: Gilsbar, Inc., P.O. Box
More informationPlease refer to your Benefit Handbook for further information about how your In-Network and Out-of- Network coverage works.
Schedule of Benefits The Harvard Pilgrim Health Care of New England USNH-STAFF/FACULTY POS Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. UI, 10/09
More informationNEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS
. (EV-4) 25/45/1000 w/access Rider NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood
More informationUnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California
CALIFORNIA SMALL GROUP UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California HMO SCHEDULE OF BENEFITS PLATINUM FOCUS-2 $0 These services are covered as indicated when authorized
More informationGILSBAR GROUP HEALTH PLAN S2202 OPTION 2 NON-GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB The Plan will cover all dependent Dependents children up to age 26 Filing Limit 12 months from date of service Mailing Address
More informationParticipating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies
Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50,000.00 lifetime major medical maximum effective 1/1/2013 Out-of-network
More informationPeak Care health plan guide. For businesses headquartered in Pierce County with 51+ employees enrolled on the plan
2019 Peak Care health plan guide For businesses headquartered in Pierce County with 51+ employees enrolled on the plan Table of contents MEDICAL PLANS.... 4 Peak Care EPO plans...5 PHARMACY PLANS.... 7
More informationSee the benefits table below. $250 per Member per Calendar Year $500 per family per Calendar Year
Schedule of s HMO MASSACHUSETTS ID: MD0000017703_A9 X This Schedule of s states any Limits and the Member Cost Sharing amounts you must pay for Covered s. However, it is only a summary of your benefits.
More informationMolina Healthcare of Washington Member Services: (800) /TTY
Benefits At-A-Glance Our goal is to provide you with the best care possible. Abortion Involuntary pregnancy termination (miscarriage) Voluntary pregnancy termination Acupuncture Ambulance Transportation
More informationIN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)
HMO-OA-CAL-15-15-0-0-03 HMO Open Access Calendar Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations
More informationSee the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM HMO MAINE ID: MD0000017741_A4 X This Schedule of s states any Limits and Member Cost Sharing amounts you must pay for Covered s. However,
More informationIN-NETWORK MEMBER PAYS. Contract Year Plan Deductible (Deductible is combined for health services and prescription drugs) $5,000 Individual
HMO-OA-CNT-HSA-5000I/10000F-07 Contract Year Benefit Summary (E) Point-Of-Service Open Access High Deductible Health Plan (HDHP) for use with a Health Savings Account (HSA) This is a brief summary of benefits.
More informationIndividual Market Schedule of Benefits
Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $150 per Member $300 per Family $8,000 per Member $16,000 per Family Out-of-Pocket Maximum
More informationFOR EMPLOYERS WITH 51+ EMPLOYEES PersonalCare Plans. Available to your employees living or working in King, Pierce, or Snohomish counties
FOR EMPLOYERS WITH 51+ EMPLOYEES PersonalCare Plans Available to your employees living or working in King, Pierce, or Snohomish counties PersonalCare Plans connect your employees doctors, hospitals, and
More informationSchedule of Benefits PPO MASSACHUSETTS
Schedule of s PPO MASSACHUSETTS ID: MD0000017711_A5 X This Schedule of s states any Limits and the amounts you must pay for Covered s. However, it is only a summary of your benefits. Please see your Handbook
More informationSchedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE ID: MD0000017736_A6 X This Schedule of s states any Limits and amounts you must pay for Covered s. However, it is only a summary
More informationMEDICAL BENEFITS. Eff. 1/1/15 Medicare Advantage is through HUMANA
Fund Name: Pipefitters Local 636 Fund ID: 7800 MEDICAL BENEFITS Revised: 10/30/18 MP Who is covered? Active Members and their Dependents HAP Po Box 02399 Detroit, MI 48202 800-957-4325 www.hap.org PRE-CERT
More informationExhibit 2 - YHP Plan Changes Service YHP Benefit Aetna Durable Medical Equipment including orthotics Prosthetic Devices Home Health Care $ 100 ded/80% to $ 5,000 annual maximum 100% up to $5,000 max Agreed
More informationIndividual Market Schedule of Benefits
Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $600 per Member $1,200 per Family $7,400 per Member $14,800 per Family Separate Prescription
More informationHEALTH PLAN SCHEDULE OF BENEFITS HIGH PERFORMANCE PPO PLAN GROUP# HPN HIGH PERFORMANCE NETWORK $300 $450 $600
GENERAL PROVISIONS Calendar Year Deductible Employee Employee + One Family HEALTH PLAN SCHEDULE OF BENEFITS HIGH PERFORMANCE PPO PLAN GROUP# 0180928001 HPN HIGH PERFORMANCE NETWORK $300 $450 $600 TIER
More informationState of Wisconsin 2013 Benefits Summary Active Employees & Non-Medicare Annuitants
Member Family Policy Annual Deductible None None Policy Co-insurance 10% unless specified below 10% unless specified below Policy Annual Maximum Out of Pocket () $500 $1,000 Policy Lifetime Benefit Maximum
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family In-Network expenses include coinsurance/copays and deductibles.
More informationRegence HSA Individual Direct Plan Highlights
Plan Features Provider choice: Member coinsurance levels are lowest for In-Network providers. If a member chooses an Out-of-Network provider, the member may be required to pay costs above the allowed amount.
More informationSCHEDULE OF BENEFITS PLAN H1
SCHEDULE OF BENEFITS PLAN H1 Effective June 1, 2018 This Plan is a High Deductible Health Plan (HDHP), designed to qualify for use with a Health Savings Account (HSA). All charges except charges for preventive
More informationSubject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply
More informationArizona Clover Health Choice PPO (040) 2019 Medical Benefits
Arizona 2019 Medical Benefits Effective Date: 1/1/2019 Version 1.0 Part D Deductible For Part D Copay information, see page 26. /year for Part D prescription drugs /year for Part D prescription drugs Out-of-Pocket
More informationFive Colleges, Inc. ~ Memorandum
Five Colleges, Inc. ~ Memorandum To: All Benefited s From: Barbara Lucey Date: October, 2017 Re: Health and Dental Insurance Health Plan Good news, we are staying with Harvard Pilgrim this year for both
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include coinsurance/copays
More informationSUMMARY OF BENEFITS Your CIGNA HealthCare Indemnity plan
SUMMARY OF BENEFITS Your CIGNA HealthCare Indemnity plan Features that Add Value The CIGNA HealthCare 24-Hour Health Information Line SM connects you to registered nurses and a library of hundreds of recorded
More informationSCHEDULE OF BENEFITS PLAN C
SCHEDULE OF BENEFITS PLAN C Effective September 1, 2016 All benefits, unless otherwise specified, are based on Usual, Customary and Reasonable (UCR) charges, or the network contracted amounts, and are
More informationSCHEDULE OF BENEFITS PLAN M7
SCHEDULE OF BENEFITS PLAN M7 Effective September 1, 2017 When you need to see a physician, a physician network, PHCS, is utilized for all physician services (primary care and specialists) and ancillary
More informationAnthem Blue Cross High HMO
Anthem Blue Cross High HMO HMO HIGH SELECT NETWORK Modified Premier HMO 10/100% This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $3,500 Individual $7,000 Family In-Network expenses include coinsurance/copays and deductibles.
More informationSCHEDULE OF BENEFITS PLAN M7
SCHEDULE OF BENEFITS PLAN M7 Effective September 1, 2016 All benefits, unless otherwise specified, are based on Usual, Customary and Reasonable (UCR) charges, or the network contracted amounts, and are
More informationAllergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review.
ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION () GRID FOR MEDICAL BENEFITS FOR DIRECTLY CONTRACTED PROVIDERS ONLY Effective 01/01/2019 Before services are provided, please check: Member
More informationRe: Health and Dental Insurance
Five Colleges, Inc. ~ Memorandum To: All Benefited s From: Barbara Lucey Date: November, 2017 Re: Health and Dental Insurance We are staying with Harvard Pilgrim as our health insurance carrier this year.
More informationPLAN DESIGN. Customer Name: High Desert & Inland Employee-Employer Trust. Effective Date: Plan: HMO Plan. Location(s): California
PLAN DESIGN Customer Name: High Desert & Inland Employee-Employer Trust Plan: HMO Plan Location(s): California Organization Name: Aetna PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum
More informationPennslyvania Green (Plan 028) 2018 Medical Benefits
Pennslyvania Green (Plan 028) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 25. $150/year for Part D prescription drugs Tiers 1 and
More informationTusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible
Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services
More informationTusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible
Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College
More informationGeorgia Green (Plan 026) 2018 Medical Benefits
Georgia Green (Plan 026) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 26. Out-of-Pocket Max $100/year for Part D prescription drugs
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: Beginning On or After 1/1/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Blue Shield Gold 80 PPO 0/25 + Child Dental Coverage for: Individual
More informationIMPORTANT INFORMATION:
Schedule of Benefits Harvard Pilgrim Health Care of New England, Inc. ELEVATEHEALTH SILVER 3500 NEW HAMPSHIRE ID: MD0000004485_ X IMPORTANT INFORMATION: This policy reflects the known requirements for
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per plan year) Out-of-Pocket Maximum (per plan year) None Individual None Family $250 Individual $500 Family In-Network expenses include coinsurance/copays and deductibles. Pharmacy
More informationSubject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply
More informationVIGILANT GROUP BENEFITS
VIGILANT GROUP BENEFITS BENEFIT PLANS AT A GLANCE This summary provides a brief overview of the Vigilant Group Benefits plans beginning January 1, 2011. PROGRAM MANAGER: Vigilant Services, Inc. 6825 SW
More informationGlobal Series Schedule of Medical & Dental Benefits Effective July May
STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED FACILITIES IN BERMUDA Standard Health Benefits PW OR SP OR PRIV ON YOUR INSURANCE
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: Beginning On or After 1/1/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Blue Shield Bronze 60 PPO 6300/75 + Child Dental Coverage for:
More informationPrincipal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)
Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17) The Services described below are covered only if all of the following
More informationUnlimited except where otherwise indicated. Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Out-of-Pocket Maximum (per calendar year) $2,000 Individual In-Network expenses include coinsurance/copays and deductibles. $4,000
More informationPrincipal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
More informationStandard Major Medical Schedule of Medical Benefits Effective June May
STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED TESTING FACILITIES IN BERMUDA Standard Health Benefits PW OR SP OR PRIV ON YOUR
More informationSUMMARY OF P BENEFITS AND SCHEDULE OF COPAYMENTS
SUMMARY OF P-10-15-250 BENEFITS AND SCHEDULE OF COPAYMENTS THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD
More informationVIGILANT GROUP BENEFITS PROGRAM. BENEFIT PLANS AT A GLANCE This summary provides a brief overview of the Vigilant Group
VIGILANT GROUP BENEFITS PROGRAM VIGILANT GROUP BENEFITS PROGRAM BENEFIT PLANS AT A GLANCE This summary provides a brief BENEFIT PLANS AT A GLANCE overview of the Vigilant Group Benefits Trust plans This
More informationGlobal Series Elite Executive Schedule of Medical & Dental Benefits Effective August May
STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED TESTING FACILITIES IN BERMUDA Standard Health Benefits SP ON YOUR INSURANCE
More informationSelect Health Schedule of Medical & Dental Benefits Effective June May
STANDARD HEALTH BENEFITS FOR SERVICES AND SUPPLIES PROVIDED BY KEMH, MID-ATLANTIC WELLNESS INSTITUTE AND GOVERNMENT APPROVED TESTING FACILITIES IN BERMUDA Standard Health Benefits PW OR SP OR PRIV ON YOUR
More information2016 OPEN ENROLLMENT RETIREE HEALTH PLANS
2016 OPEN ENROLLMENT RETIREE HEALTH PLANS SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2016 Benefits Pays all but first
More informationDisclosure Form CSAC EIA - EL DORADO COUNTY HMO $15 Member Services
Disclosure Form 34936 CSAC EIA - EL DORADO COUNTY HMO $15 Member Services 800-464-4000 Principal Benefits for Kaiser Permanente Traditional Plan (1/1/18 12/31/18) Health Plan believes this coverage is
More informationHealthcare Eligibility Benefit Inquiry and Response. 270/271 Companion Guide
Healthcare Eligibility Benefit Inquiry and Response 270/271 Companion Guide Table of Contents Purpose...1 Preparation and Testing Requirements...1 Contact Information...1 System Availability...1 Batch
More informationFamily Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) or more Members
Benefit Summary 128742 & 35995 ACWA JPIA Principal Benefits for Kaiser Permanente Traditional HMO Plan (1/1/18 12/31/18) Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18
More informationPrincipal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16)
SISC - SELF-INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16) The Services described below are covered only if all of the following
More informationOutpatient Specialty Referral Request Types
What is a request type? Request types are templates created for use with Health Net Federal Services, LLC s (HNFS) online referral and authorization submission tools, available at www.tricare-west.com
More informationBlue Shield Bronze 60 HDHP PPO Provider Network: Exclusive
Blue Shield Bronze 60 HDHP PPO Provider Network: Exclusive Evidence of Coverage and Health Service Agreement Individual and Family Plans An independent member of the Blue Shield Association (Intentionally
More informationPrincipal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)
Benefit Summary 35876D 35876 SCHOOLS INSURANCE GROUP #35876 Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19) Plan Out-of-Pocket Maximum For Services subject
More informationNational Accounts Utilization Management Requirements New York based Accounts
National Accounts Utilization Management Requirements New York based Accounts The table below reflects our National Accounts standard Utilization Management (UM) requirements. For precertification, please
More informationSummary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18)
SISC - KPSA $0 Summary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18) Plan Out-of-Pocket Maximum For Services subject to the maximum, you will not pay any
More informationPrincipal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)
Disclosure Form SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following
More informationPrincipal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)
Benefit Summary 128742, 35995 ACWA/JPIA Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16) The Services described below are covered only if all of the following conditions are satisfied:
More information2017 Individual & Family Plan Options Elite Network
Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Elite Gold Elite Gold Elite Gold Elite Gold Deductible* 30 / 60 Wise Savings Standard Deductible
More information2016 OPEN ENROLLMENT RETIREE HEALTH PLANS
2016 OPEN ENROLLMENT RETIREE HEALTH PLANS SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2016 Benefits Pays all but first
More informationSpecialty Referrals. Start of Code Range (Procedure Low Code) Request Request Profile Description. End of Code Range (Procedure High Code)
What is a request profile? profiles are templates created for use with specialty referral, outpatient authorization, and outpatient behavioral health service request submissions. Each request profile has
More information2010 Summary of Benefits HMO Mandated Plan ($30/$40/$1,000 IP/$2,500 Rx Ded) Small Group (Maryland)
2101 East Jefferson Street, Rockville, Maryland 20852 2010 Summary of Benefits HMO Mandated Plan ($30/$40/$1,000 IP/$2,500 Rx Ded) Small Group (Maryland) The following is a limited description of benefits
More information2017 Individual & Family Plan Options ProHealth on the Elite Network (Waukesha County)
Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits ProHealth Gold ProHealth Gold ProHealth Gold ProHealth Gold Deductible* 30 / 60 Wise Savings
More informationYour 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010
Inpatient Services Inpatient hospital care Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010 Hospital days are unlimited. Covered services include, but are not limited to, the following:
More information