Participating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies

Size: px
Start display at page:

Download "Participating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies"

Transcription

1 Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50, lifetime major medical maximum effective 1/1/2013 Out-of-network medical deductible is $ per calendar year OptumRX-$25.00 deductible with 20% co-payment. Maximum payable by the Fund per calendar year is a $1, Adoption Acupuncture visit All Scans Allergy Injections Allergy Treatment Ambulance True Emergent $40.00 co-payment $10, Calendar year max ; 16 visits per Calendar Year; 1 visit per day; Ambulance Non Emergent not covered not covered Ambulatory Surgery $50.00 co-payment Anesthesia Anesthesia Maternity Annual Physical Assistant Surgeon Birthing Center Breast Sonogram 75% of Fund's fee schedule; Cardiac Rehabilitation 36 visits per Calendar Year; Chemotherapy Chiro $15.00 co-payment schedule; 1 visit per day; 24 visits per Calendar Year; Chiro X-rays 4 x-rays per Calendar Year; Diabetic Supplies Diabetic Education with Dietician office visit Diagnostic Testing Office Diagnostic Independent lab / Professional charge Diagnostic Testing OP / Hospital Charge Diagnostic Testing OP in Free Standing Facility 100% of negotiated Pulmonary Function Test Tilt Table Testing Electrophysiological Study Page 1 of 5

2 Video EEG Mammogram Dialysis Office Dialysis OP Facility Dialysis OP Physician visit Dietician / Nutritionist office visit DME / Medical Equipment ER Non Emergent Facility ER Emergent Facility ER Non Emergent Physician ER Emergent Physician Gastric Bypass, Lap Band, Sleeve Surgery Gastric Assistant Surgery Genetic Testing -independent lab $ co-payment / waived if admitted 75% of the Fund's Negotiated 6 visits per Calendar Year; Prior approval by the Fund is deductible waived $ Calendar year max combined physician ; charges; Prior approval $ Calendar year max combined physician charges; Prior approval. Genetic Counciling not covered. Genetic Testing-OP Hospital Genetic Counciling not covered. Halfway House Hearing Aid Right schedule; $ per Calendar year max ; Hearing Aid Left schedule; $ per Calendar year max ; Home Health Care schedule; ; 200 visits per Calendar Year; Combined with Private Duty Nursing; Hospice Care IP schedule; Hospice Care home schedule; Immunizations IUD supplies Infertility Anesthesia $5, Calendar year max ; combined all Infertility Facility $5, Calendar year max; combined all Page 2 of 5

3 Infertility Pathology / Lab Infertility RX OptumRX 20% co-payment, deductible applies infertility RX services; prior approval required for certain medication. (NOTE: not to exceed a Infertility Physician $ per stay copayment Inpatient hospital Illness / / $ max There may be a patient responsibility when using a Room & Board per calender year. non-participating facility that will not negotiate. $1, global allowance; prior approval Lasik Surgery Left eye $1, global allowance; prior approval Lasik Surgery Right eye Lithotripsy Physician Lithotripsy Facility $50.00 co-payment schedule; ; Maternity C Section $4,000 max per delivery Maternity Midwife Maternity Regular Delivery Medical Equipment / Rentals and Purchases schedule; ; $3,200 max per delivery schedule; ; $3,600 max per delivery schedule; See DME Medication Coverage Outside Of The RX Plan Abuse Inpatient Abuse Outpatient (MD) (PhD) only Abuse Outpatient Social Worker (LCSW) only Abuse Outpatient Group Therapy (MD) (PhD) (LCSW) only Abuse Outpatient Family Therapy (MD) (LCSW) only J codes for Hep C, Cancer, MS, HIV/AIDS, Epilepsy, Crohn's Disease and Diabetes; Arthritis; prior approval through the Fund is required. Prior approval through the fund is required $ per visit; $85.00 per visit; $55.00 per visit; $55.00 per visit; MRI's and MRA's Newborn Hearing IP Physician charges Nerve Block Injections Neuropsychological Testing $40.00 co-payment up to 4 per Calendar Year; 12 units per test per Calendar Year; prior approval required Page 3 of 5

4 Occupational Therapy Physical Therapy Speech Therapy Visual Therapy Orthotics Orthotripsy Office visit Specialist Office visit General Practitioner $15.00 co-payment Office Surgery Physician charges Outpatient Surgical Facility / Ambulatory Surgery $50.00 co-payment Partial Hospitalization Inpatient or Out patient Pathology Physician IP Pathology Outpatient PEMG deductible waived Pharmocogenetic schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required $1, Calendar Year maximum; prior approval required $4, Global Calendar year maximum; prior approval required Podiatry Private Duty Nursing Pre-Surgical Testing Prior approval through the fund is required for surgery. PT and strapping not covered. $10, per Calendar year; Prior approval Must be performed within seven days of the surgical procedure. Prescription RX (OptumRX) Prosthetics Pulmonary Rehab 20% co-payment, $25.00 deductible per person per Calendar year. Prior approval required for certain medications. NOTE: There is a Calendar year maximum of $5, combined for all infertility RX services, not to exceed a combined $10, yearly max Medical / RX. Prior approval 42 visits per Calendar year; Reconstructive Surgery Sclerotherapy Skilled Nursing Facility Sleep Study up to a maximum of $3, Surgical Center $50.00 co-payment Prior approval is required. $2,600 per Calendar year maximum both legs; Prior approval is required. 60 days per Calendar year; 75% of the Fund's negotiated ; up to a maximum of $3, $3,000 per Calendar year max; Page 4 of 5

5 Swift MD Synagis injections Ultrasound Pregnancy first three Ultrasound Pregnancy after the three limit Prior approval Urgent Care Clinics Wig Important Questions Answers Why this matters What is the Annual maximum $200, All services unless otherwise indicated apply to the annual maximum. Once the annual maximum has been exhausted no benefits are payable for that year. Other annual limits apply to certain benefits as specified in the Schedule of Benefits What is the overall deductible $ The sum of out of pocket expenses that each participant must pay each calendar year before the Plan begins to pay benefits. The deductible is applied to all services unless otherwise indicated. Are there other deductibles for specific services N/A No, however there are certain services where the deductible does not apply Is there an out-of-pocket limit on my expenses No What is not included in the outof-pocket N/A Is there an overall limit on what the insurer pays Yes See the schedule of benefits. Does this plan use a network of providers? Yes EBCBS Do I need a referral to see a specialists No Is there a Prescription Drug Card Yes Prescriptions are handled through Caremark Are there services this plan doesn't cover Yes See Limitations and exclusions Page 5 of 5

MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold

MetroPlus 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 information

UNIVERSITY OF THE INCARNATE WORD, S2855 BRONZE RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET

UNIVERSITY 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 information

2018 Anthem Blue Cross HMO*

2018 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 information

MVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange

MVP 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 information

2018 Anthem Blue Cross Senior Secure HMO - Southern CA - Post 65 (Medicare Eligible)*

2018 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 information

MEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS

MEDICAL & 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 information

MEDICAL & 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: 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 information

UNIVERSITY OF THE INCARNATE WORD, S2855 PPO PLAN GRANDFATHERED PLAN BENEFIT SHEET

UNIVERSITY 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 information

UNIVERSITY OF THE INCARNATE WORD, S2855 SILVER RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET

UNIVERSITY 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 information

Schedule 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 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 information

Schedule 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 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 information

Schedule 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 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 information

Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017

Baltimore 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 information

MEDICAL SCHEDULE OF BENEFITS

MEDICAL 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 information

2016 Rochester Regional Health PPO Medical Plan Summary

2016 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 information

GILSBAR GROUP HEALTH PLAN S2202 OPTION 2 NON-GRANDFATHERED PLAN BENEFIT SHEET

GILSBAR 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 information

NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF BENEFITS SUPREME BENEFITS

NEW 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 information

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information BluePoint 3 Benefit Time Period: 06/01/2015-05/31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services

More information

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information

Benefit 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 information

New York Essential Plan cost-sharing matrix

New 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 information

Please refer to your Benefit Handbook for further information about how your In-Network and Out-of- Network coverage works.

Please 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 information

*** NOTE *** ALL services subject to deductible, unless otherwise noted.

*** 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 information

Schedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE

Schedule 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 information

2018 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 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 information

Excellus BluePPO Signature Hybrid 5

Excellus 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 information

See the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year

See 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 information

NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS

NEIGHBORHOOD 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 information

Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible

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 information

Excellus BluePPO Signature Deduct 3

Excellus 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 information

Connecticut Teachers' Retirement Board 2019 Medicare Supplement Plan Benefits -- Administered By Stirling Benefits. General information

Connecticut Teachers' Retirement Board 2019 Medicare Supplement Plan Benefits -- Administered By Stirling Benefits. General information Provider access Covered Benefits Deductible General information All providers who accept If covers a charge, then the TRB plan covers that charge The 2019 deductible is $185. The member pays the Part B

More information

Individual Market Schedule of Benefits

Individual 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 information

National Accounts Utilization Management Requirements New York based Accounts

National 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 information

UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California

UnitedHealthcare 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 information

Individual Market Schedule of Benefits

Individual 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 information

See the benefits table below. $250 per Member per Calendar Year $500 per family per Calendar Year

See 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 information

SUMMARY OF P BENEFITS AND SCHEDULE OF COPAYMENTS

SUMMARY 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 information

Schedule of Benefits PPO MASSACHUSETTS

Schedule 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 information

Allergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review.

Allergen 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 information

Exhibit 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 information

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN 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 information

HealthyBlue Living SM

HealthyBlue 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

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN 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 information

2016 OPEN ENROLLMENT RETIREE HEALTH PLANS

2016 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 information

Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)

Principal 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 information

Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16)

Principal 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 information

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN 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 information

Arizona Clover Health Choice PPO (040) 2019 Medical Benefits

Arizona 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 information

Georgia Green (Plan 026) 2018 Medical Benefits

Georgia 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 information

Pennslyvania Green (Plan 028) 2018 Medical Benefits

Pennslyvania 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 information

Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)

Principal 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 information

Molina Healthcare of Washington Member Services: (800) /TTY

Molina 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 information

Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)

Principal 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 information

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

PLAN 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 information

Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)

Principal 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 information

Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)

Principal 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 information

Family Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) or more Members

Family 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 information

Subject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing

Subject 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 information

2016 OPEN ENROLLMENT RETIREE HEALTH PLANS

2016 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 information

IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)

IN-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 information

Unlimited except where otherwise indicated. Primary Care Physician Selection

Unlimited 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 information

SCHEDULE OF BENEFITS PLAN M7

SCHEDULE 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 information

Summary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18)

Summary 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 information

PLAN 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. 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 information

IN-NETWORK MEMBER PAYS. Contract Year Plan Deductible (Deductible is combined for health services and prescription drugs) $5,000 Individual

IN-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 information

2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization 2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services

More information

SCHEDULE OF BENEFITS PLAN C

SCHEDULE 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 information

MEDICAL BENEFITS. Eff. 1/1/15 Medicare Advantage is through HUMANA

MEDICAL 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 information

Tusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible

Tusculum 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 information

SCHEDULE OF BENEFITS PLAN M7

SCHEDULE 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 information

IMPORTANT INFORMATION:

IMPORTANT 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 information

SCHEDULE OF BENEFITS PLAN H1

SCHEDULE 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 information

Global Series Schedule of Medical & Dental Benefits Effective July May

Global 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 information

Section 3 - Psychiatric cover (read in conjunction with Section 1)

Section 3 - Psychiatric cover (read in conjunction with Section 1) Table of enefits HealthPlus Platinum pplicable to new registrations or renewals on/or after 1 st November, 2018. This Table of enefits must be read in conjunction with your Hospital Plan Terms and Conditions

More information

Anthem Blue Cross High HMO

Anthem 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 information

Table of Benefits HealthPlus Excess

Table of Benefits HealthPlus Excess Table of enefits HealthPlus Excess pplicable to new registrations or renewals on/or after 1 st July, 2018. This Table of enefits must be read in conjunction with your Hospital Plan Terms and Conditions

More information

State of Wisconsin 2013 Benefits Summary Active Employees & Non-Medicare Annuitants

State 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 information

Section 3 - Psychiatric cover (read in conjunction with Section 1)

Section 3 - Psychiatric cover (read in conjunction with Section 1) Table of enefits HealthPlus Choice pplicable to new registrations or renewals on/or after 1 st May, 2018. This Table of enefits must be read in conjunction with your Hospital Plan Terms and Conditions

More information

Standard Major Medical Schedule of Medical Benefits Effective June May

Standard 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 information

Tusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible

Tusculum 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 information

Outpatient Specialty Referral Request Types

Outpatient 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 information

Global Series Elite Executive Schedule of Medical & Dental Benefits Effective August May

Global 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 information

Select Health Schedule of Medical & Dental Benefits Effective June May

Select 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 information

Subject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing

Subject 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 information

IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.

IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA. , PA Code Matrix IMPORTANT NOTICES This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA unless there is a

More information

Healthcare Eligibility Benefit Inquiry and Response. 270/271 Companion Guide

Healthcare 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 information

SUMMARY OF BENEFITS Your CIGNA HealthCare Indemnity plan

SUMMARY 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 information

MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization

MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network

More information

MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018

MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018 MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018 FOR MMP MEDICAID, PLEASE REFER TO YOUR STATE MEDICAID PA GUIDE FOR ADDITIONAL PA REQUIREMENTS Refer to Molina

More information

II. BENEFITS AND SERVICES

II. BENEFITS AND SERVICES II. S AND SERVICES A. HealthChoice Benefits This table shows the healthcare services and benefits that all HealthChoice enrollees can get when they need them. We offer other services not listed here. (See

More information

ORBE Summary of Benefits

ORBE Summary of Benefits www.wellaway.com ORBE Summary of Benefits www.wellaway.com Summary of Benefits Annual Limit 5,000,000 Coinsurance ORBE 90 ORBE 100 WellAway s share of costs on a covered service Your share of costs on

More information

not require PA. review. MHT

not require PA. review. MHT IMPORTANT NOTICES This document is updated quarterly. Pleasee check this document prior to PA submission as codes may be removed or added. Alll codes listed require PA unless there is a Plan spec cific

More information

Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO

Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.

More information

Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010

Your 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

CPT-4 3 HCPCS AMBULANCE I A0021-A0999 C9000-C9010, C9105 J0120-J8999 Q3014, Q3017 AMBULATORY SURGERY

CPT-4 3 HCPCS AMBULANCE I A0021-A0999 C9000-C9010, C9105 J0120-J8999 Q3014, Q3017 AMBULATORY SURGERY TRICARE ENCOUNTER DATA (TED) CHAPTER 2 ADDENDUM F DATA REQUIREMENTS - FOR TYPE OF SERVICE TYPE OF SERVICE DESP. FOR TYPE OF SERVICE 1 AMBULANCE I 93005-93041 A0021-A0999 C9000-C9010, C9105 Q3014, Q3017

More information

Plan Units. Hospital Confinement $200 per day of covered confinement. Inpatient Drugs and Medicines $30 per day while hospital confined $2,000

Plan Units. Hospital Confinement $200 per day of covered confinement. Inpatient Drugs and Medicines $30 per day while hospital confined $2,000 Hospital Benefits Hospital Confinement $200 per day of covered confinement Extended Benefits $400 Attending Physician $40 per day; begins on day 91 of continuous confinement; in lieu of all other benefits

More information