Schedule of Benefits Harvard Pilgrim Health Care, Inc.
|
|
- Loren Manning
- 6 years ago
- Views:
Transcription
1 Schedule of Benefits Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM-LAHEY SELECT HMO OOA MASSACHUSETTS 6-SPF, 01/13 MD Please Note: In this plan, Member s have access to network benefits only from the providers in the Harvard Pilgrim-Lahey Select network. This network includes a tiered provider network. In this plan, Members pay different levels of Copayments or Coinsurance depending on the tier of the provider delivering a covered service or supply. Please consult the Harvard Pilgrim-Lahey Select Provider Directory or visit the provider search tool at to determine the tier of Providers in the Harvard Pilgrim-Lahey Select Network. This Schedule of Benefits summarizes your Benefits under The Harvard Pilgrim Lahey-Select HMO (the Plan) and states the Member Cost Sharing amounts that you must pay for Covered Benefits. This is only a summary of your benefits. Please see your Benefit Handbook for detailed information on benefits covered by the Plan and the terms and conditions of coverage. This plan does not provide coverage for outpatient prescription drugs. Your coverage for prescription drugs is administered by a third party named CVS Caremark. If you have questions regarding your pharmacy coverage, CVS Caremark can be reached at Services are covered when Medically Necessary. Subject to the exceptions listed in the section of the Benefit Handbook titled, How the Plan Works all services must be (1) provided or arranged by your Primary Care Provider (PCP) and (2) provided by a Harvard Pilgrim-Lahey Select Plan Provider. These requirements do not apply to care needed in a Medical Emergency. You always have coverage for care in a Medical Emergency. A Referral from your PCP is not needed. In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number. Your emergency room Member Cost Sharing is listed below under the heading Emergency Room Care. We use clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member s care. Members or their practitioners may obtain a copy of our clinical review criteria applicable to a service or procedure for which coverage is requested. Clinical review criteria may be obtained by calling ext Your Covered Benefits are administered on a calendar year basis. Your calendar year begins on January 1 st and ends on December 31 st of each year. MEMBER COST SHARING Members are required to share the cost of the Covered Benefits provided under the Plan. This section describes the payments for which you are responsible, called Member Cost Sharing. The tables, set forth below, show the specific Member Cost Sharing amounts for the different services covered by the Plan. 1
2 PREVENTIVE SERVICES No Member Cost Sharing applies to certain preventive services when received by an adult from a Tier 1 or Tier 2 provider. For pediatrics (up to age 19), there is no Member Cost Sharing when received from a Tier 1, Tier 2 or Tier 3 provider. These services are summarized below and further described in the tables later in this Schedule of Benefits: Annual preventive gynecological examinations Immunizations Specified Preventive services and tests Routine prenatal and routine postpartum care Routine well physical examinations (including well child care, vision and auditory screening for children, and health education) TIERED PROVIDERS Most hospitals and physicians covered by the Plan are placed into one of three benefit levels or tiers. Member Cost Sharing for these providers depends upon the tier in which a provider is placed. Tier 1 and Tier 2 are the lower cost tiers, and Tier 3 is the higher cost tier. Only acute care hospitals, Primary Care Provider (PCPs) and medical specialists are assigned to one of three tiers. All other covered providers are assigned to Tier 2. In some cases, a provider may practice at more than one location and may have a different tier assigned to each location. Keep in mind that different out-of-pocket costs may apply to the same provider based upon where you are treated by that provider. You can lower your out-of-pocket cost by selecting the physicians and hospitals in the lower tiers. The tables set forth below list the Member Cost Sharing for each type of tiered service. The Plan s Provider Directory lists all Plan Providers and their associated tier. You can access the Provider Directory at Please note: When you choose a PCP, it is important to consider the tier of the hospital that your PCP uses. For example, a Tier 2 PCP may admit patients to a Tier 3 Hospital. COINSURANCE Coinsurance is a percentage of the cost for certain services that is payable by the Member. COPAYMENTS A Copayment is a fixed dollar amount that is payable by the Member for certain covered services. Copayments are due at the time services are rendered or when billed by the provider. Different Copayments apply depending on the type of service, the tier placement of the provider and the location of service. 2
3 DEDUCTIBLES A Deductible is a specific annual dollar amount that is payable by the Member for Covered Benefits received each calendar year before any benefits subject to the Deductible are payable by the Plan. If a family Deductible applies, it is met when any combination of Members in a covered family incur expenses for services to which the Deductible applies. Your Plan s Deductible amounts are listed on page 4. The Deductible applies only to certain services in Tier 3 under the Plan. You can learn about the services that require payment of a Deductible and the amounts from the tables below. Deductible amounts are incurred on the date of service. Your Plan has both an individual Deductible and a family Deductible. However, the family Deductible only applies if you have family coverage. Unless a family Deductible applies, you are responsible for the individual Deductible for Covered Benefits each calendar year. If you have family coverage, the Deductible can be satisfied in one of two ways: 1. If a Member of a covered family meets the individual Deductible, then services for that Member that are subject to that Deductible are covered by the Plan for the remainder of the calendar year. 2. If any number of Members in a covered family collectively meet the family Deductible, then all Members of the covered family are deemed to have met the Deductible for the remainder of the calendar year. Any Deductible amount incurred for any Covered Service during a calendar year will apply toward the Deductible for that year. For example, a Member incurred a Deductible for care in a Tier 3 hospital in January. The Deductible amount incurred in January will apply toward the Deductible payable under the Plan for any Covered Service received later in the calendar year. Once the Deductible is met, no further Deductible applies for the remainder of the calendar year. However, coverage by the Plan remains subject to any other Member Cost Sharing that may apply. OUT-OF-POCKET MAXIMUM You have an Annual Out-of-Pocket Maximum of $3,000 per Member or $6,000 per family, which includes Emergency Room Copayments, Deductible and Coinsurance. Cost sharing that applies to the Out-of-Pocket Maximum will accumulate across all tiers. Copayment for office visits, Physical, Occupational, and Speech Therapy, and outpatient prescription drugs, and any charges in excess of the Usual, Customary and Reasonable Charge do not apply to the Out-of-Pocket Maximum. 3
4 Coinsurance None 20% Coinsurance Office Visit Copayments Pediatric (up to age 19) Your Plan has a $15 Copayment per visit Your Plan has a $15 Copayment per visit Adult Your Plan has a $15 Copayment per visit Your Plan has a $75 Copayment per visit Deductible Out-of-Pocket Maximum Includes the following Cost Sharing: Emergency Room Copayment, Deductible and Coinsurance. Cost sharing that applies to the Out-of-Pocket Maximum will accumulate across all tiers. Excludes the following cost sharing: Copayments for office visit, Physical, Occupational and Speech Therapies, and Copayments for outpatient prescription drugs. None $3,000 per Member per calendar year $6,000 per family per calendar year $1,000 per Member per calendar year $2,000 per family per calendar year 4
5 Ambulance Transport Emergency ambulance transport Non-emergency ambulance transport Autism Spectrum Disorders Treatment j Professional Services Coverage for the treatment of Autism Spectrum Disorders is provided for all of the services otherwise covered under your Plan. However, no benefit limit applies to services for the treatment of Autism Spectrum Disorders. Applied Behavior Analysis $15 Copayment No benefit limit applies to this service Cardiac Rehab $15 Copayment per visit $35 Copayment per visit Chemotherapy - Outpatient $35 Copayment per visit Clinical Trials for the Treatment of Cancer Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Dental Services Emergency dental care Extraction of teeth impacted in bone (when done in an office setting) Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided in a dentist s office, see Physician and Other Professional Office Visits. For services provided in a hospital emergency room, see Emergency Room Care. $15 Copayment per visit 5
6 Dental Services (continued) Preventive Dental $15 Copayment per visit Care for children (up to age 13) Diabetes Services and Supplies Self management and training/diabetic eye examinations/foot care $15 Copayment per visit $75 Copayment per visit Dialysis Diabetes equipment Pharmacy supplies Your medical plan does not provide coverage for outpatient prescription drugs. For questions on prescription drug coverage, please contact CVS Caremark at $35 Copayment For Hospital Inpatient dialysis services, please see Hospital Inpatient Services for your Member Cost Sharing. Installation of home equipment is covered up to $300 in a Member's lifetime. Durable Medical Equipment and Prosthetic Devices Early Intervention Services $15 Copayment per visit Emergency Admission Services Emergency Room Care $100 Copayment per visit Family Planning Services This Copayment is waived if admitted to the hospital directly from the emergency room. Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. 6
7 Hearing Aids (for Members up to the age of 22) Limited to No charge $2,000 per hearing aid every 36 months, for each hearing impaired ear Home Health Care Hospice Services Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services or Skilled Nursing Facility Care. Hospital Inpatient Services j 20% Coinsurance after Deductible has been met House Calls $15 Copayment per visit $75 Copayment per visit Human Organ Transplant Services Hypodermic Syringes and Needles $15 Copayment for Pediatrics (up to age 19) Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Your medical plan does not provide coverage for outpatient prescription drugs. For questions on prescription drug coverage, please contact CVS Caremark at
8 Infertility Treatments (see the Benefit Handbook for details)j 20% Coinsurance after Deductible has been met Laboratory and Radiology Services Hospital based and Non-hospital based laboratory and x-rays Non-hospital based High End Radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) Hospital based High End Radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) 20% Coinsurance after Deductible has been met No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, below. Low Protein Foods j Limited to $5,000 per calendar year 8
9 Maternity Care Routine outpatient prenatal and postpartum care Preventive services and screenings including: counseling about alcohol and tobacco use, services to promote breastfeeding, routine urinalysis and screenings for the following: asymptomatic bacteriuria; hepatitis B infection; HIV and screenings for STDs chlamydia, gonorrhea and syphilis); iron deficiency anemia; and Rh (D) incompatibility. $75 Copayment per visit Please see Preventive Services and Tests, on page 12, for additional services and tests covered with no Member Cost Sharing. Please note: Routine prenatal and postpartum care is usually received and billed from the same Provider as a single or bundled service. Different Member Cost Sharing may apply to any specialized or nonroutine service that is billed separately from your routine outpatient prenatal and postpartum care. For example, for services provided by another physician or specialist, see Physician and Other Professional Office Visits for your applicable Member Cost Sharing. Please see your Benefit Handbook for more information on maternity care. Routine and non-routine nursery care for the newborn, including prophylactic medication to prevent gonorrhea and screenings for the following: hearing loss; congenital hypothyroidism; phenylketonuria (PKU); and sickle cell disease. 20% Coinsurance after Deductible has been met Hospital inpatient services 20% Coinsurance after Deductible has been met Please Note: If a newborn is released from the hospital and re-admitted at a later date, the cost sharing will follow that of Hospital Inpatient Services 9
10 Medical Formulas Mental Health Care (Including the Treatment of Substance Abuse Disorders)j Please note: This Plan is subject to Federal Mental Health Parity Inpatient Mental Health Care Services Intermediate Mental Health Care Services Acute residential treatment (including detoxification), crisis stabilization and in-home family stabilization Intensive outpatient programs, partial hospitalization and day treatment programs Outpatient Mental Health Care Services Group therapy: $15 Copayment per visit Individual therapy: $15 Copayment per visit Detoxification $15 Copayment per visit Medication management $15 Copayment per visit Psychological testing and neuropsychological assessment Performed by a Licensed Mental Health Professional $15 Copayment per visit Performed by a Neurologist or other medical specialist Ostomy Supplies $15 Copayment per visit $75 Copayment per visit $15 Copayment for Pediatrics (up to age 19) 10
11 Physician and Other Professional Office Visits (This includes all covered Providers unless otherwise listed in this Schedule of Benefits)j Routine examinations for preventive care Routine physical examinations, annual gynecological examinations, school, camp, sports and premarital examinations Routine hearing examinations and tests Health education No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, on page 12. $75 Copayment per Visit for Pediatrics (up to age 19) Sickness and injury care Examinations and Consultations, including: Medication management Nutritional counseling Administration of allergy injections $15 Copayment per visit $75 Copayment per visit $10 Copayment per visit $15 Copayment for Pediatrics (up to age 19) 11
12 Preventive Services and Tests j This benefit is limited to the preventive laboratory and pathology tests and screenings as defined by federal law. No Member Cost Sharing applies to the following services when provided to an adult by a Tier 1 or Tier 2 provider. For pediatrics (up to age 19), there is no Member Cost Sharing when provided by a Tier 1, Tier 2 or Tier 3 provider. Abdominal aortic aneurysm screening (for males one time only, if ever smoked) Alcohol misuse screening and counseling (primary care visits only) Aspirin for the prevention of heart disease (primary care counseling only) Autism screening (for children at 18 and 24 months of age primary care visits only) Behavioral assessments (developmental surveillance, for children of all ages primary care visits only) Blood pressure screening Breast cancer chemoprevention counseling (only for women at high risk for Breast Cancer and low risk for adverse effects of chemoprevention) Breast cancer screening, including mammograms and genetic susceptibility screening Cervical cancer screening, including pap smears Cholesterol screening (for adults only) Colorectal cancer screening, including colonoscopy, sigmoidoscopy and fecal occult blood test Depression screening (primary care visits only) Diabetes screenings Diet counseling Dyslipidemia screening (for children at high risk for higher lipid levels) Hemoglobin A1c Hepatitis B testing HIV screening Immunizations, including flu shots (for children and adults as appropriate) Iron deficiency prevention (primary care counseling for children age 6 to 12 months only) Lead screening (for children at risk) Microalbuminuria test Obesity screening Osteoporosis screening (to begin at age 60 for women at increased risk) Ovarian cancer susceptibility screening Sexually transmitted diseases STDs screenings and counseling Tobacco use counseling (primary care visits only) Total cholesterol tests Tuberculosis skin testing Vision screening (children to age 5 only) Please see the Maternity Care benefit for additional services and tests covered with no Member Cost Sharing. Under federal law the list of preventive services and tests covered under this benefit may change periodically based on the recommendations of the following agencies: a. Grade A and B recommendations of the United States Preventive Services Task Force; b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and c. With respect to services for woman, infants, children and adolescents, the Health Resources and Services Administration. Information on the recommendations of these agencies may be found on the web site of the US Department of Health and Human Services at: Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordance with changes in the recommendations of the agencies listed above. 12
13 Radiation Treatment - Outpatient $35 Copayment per visit Reconstructive Surgery Rehabilitation Hospital Care - Limited to 60 days per calendar year Your Member Cost Sharing will depend upon the types of services provided and the tier placement of the provider rendering services, as listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Rehabilitation Therapy - Outpatient Occupational therapy - Limited to 30 visits per calendar year Physical therapy - Limited to 30 visits per calendar year Pulmonary rehabilitation therapy $15 Copayment per visit $35 Copayment per visit Scopic Procedures - Outpatient Diagnostic and Therapeutic Colonoscopy, endoscopy and sigmoidoscopy No Member Cost Sharing applies to certain preventive care services. See Preventive Services and Tests, listed on page 12. Skilled Nursing Facility Care - Limited to 100 days per Your Member Cost Sharing will depend upon where the service is provided and the tier placement of the provider rendering services, as listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. calendar year Speech-Language and Hearing Services Speech Therapy $15 Copayment per visit $35 Copayment per visit 13
14 Surgery Outpatient 20% Coinsurance after Deductible has been met Temporomandibular Joint Dysfunction Services (medical treatment only)j Your Member Cost Sharing will depend upon the types of services listed in this Schedule of Benefits. For example, for services provided by a physician, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. Vision Services Routine eye examinations - Limited to (1 per calendar year) $15 Copayment per visit $75 Copayment per visit $15 Copayment for Pediatrics (up to age 19) Vision hardware for special conditions (see the Benefit Handbook for details) Voluntary Sterilization Your Member Cost Sharing will depend upon where the service is listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services Voluntary Termination of Pregnancy Your Member Cost Sharing will depend upon where the service is listed in this Schedule of Benefits. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services Wigs and Scalp Hair Prostheses when needed as a result of any form of cancer or leukemia, alopecia areata, alopecia totalis or permanent hair loss due to injury j - Limited to $350 per calendar year (see the Benefit Handbook for details) 14
See Covered Benefits below. None. $2,000 per Member per calendar year $4,000 per family per calendar year. Member Cost Sharing:
Schedule of s THE HARVARD PILGRIM HMO MASSACHUSETTS ID: MD0000002768 CODE: 7-SYF This Schedule of s summarizes your s under The Harvard Pilgrim HMO (the Plan) and states the Member Cost Sharing amounts
More informationSchedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM PPO MASSACHUSETTS
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM PPO MASSACHUSETTS ID: MD0000002656 CODE: 2-SYF This Schedule of s summarizes your benefits under The Harvard Pilgrim PPO (the Plan) and
More informationSee Covered Benefits 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: MD0000002653_F2 X This Schedule of s summarizes your s under The Harvard Pilgrim HMO (the Plan) and states the Member Cost
More informationSchedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM BEST BUY HMO 2000 MASSACHUSETTS DEDUCTIBLE
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM BEST BUY HMO 2000 MASSACHUSETTS ID: MD0000000391 CODE: RW-X This Schedule of s summarizes your s under The Harvard Pilgrim Best Buy HMO
More informationplease refer to our internet site, or contact the Member Services
Schedule of s HPHC Insurance Company, Inc. THE BEST BUY HSA PPO PLAN MAINE ID: MD0000000149_E3 X This Schedule of s summarizes your benefits under The Best Buy HSA PPO Plan (the Plan) and states the Member
More informationSchedule of Benefits
CI, 12/10 Schedule of Benefits Standard A Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details.
More informationHPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY DEDUCTIBLE TIERED COPAYMENT PPO PLAN MAINE
ID: MD0000003250 X Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY DEDUCTIBLE TIERED COPAYMENT PPO PLAN MAINE This Schedule of s summarizes your benefits under the The HPHC Insurance
More informationSchedule of Benefits HDHP WITH HSA MASSACHUSETTS
Schedule of Benefits HDHP WITH HSA MASSACHUSETTS ID: MD0000017710_A9 X This Schedule of Benefits states any Benefit Limits and amounts you must pay for Covered Benefits. However, it is only a summary of
More informationSchedule of Benefits. Massachusetts. Service
Schedule of Benefits Services listed below are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. 2014_MD2377
More informationSchedule of Benefits
Schedule of Benefits Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. 0K, 11/10 MD0000000422
More informationSchedule of Benefits
Schedule of Benefits Services listed below are covered when Medically Necessary. Please see your Benefit Handbook for details. 0E, 11/10 MD0000000412 Member Cost Sharing Deductible: Your Plan has a Deductible
More informationIMPORTANT INFORMATION:
Schedule of Benefits ElevateHealth Options HMO NEW HAMPSHIRE ID: MD0000018209_A13 X Coverage under this Plan is under the jurisdiction of the New Hampshire Insurance Commissioner. IMPORTANT INFORMATION:
More informationSchedule of Benefits
Schedule of Benefits Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. 5-LW, 11/10 MD0000000621
More informationSchedule of Benefits
E-LW, 11/10 MD0000001012 Schedule of Benefits Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for
More informationGIC Employees/Retirees without Medicare
GIC Active Employees & Retirees without Medicare 7/1/18 GIC Employees/Retirees without Medicare HMO Summary of Benefits Chart This chart provides a summary of key services offered by your Health New England
More informationSchedule of Benefits The Harvard Pilgrim Best Buy HMO 500
Schedule of Benefits 500 Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. Member Cost
More informationYour Plan has a $500 per Member Deductible and a $1,000 per family Deductible per Plan Year.
Schedule of Benefits Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. RW-V, 1/11 MD0000000387
More informationSchedule of Benefits
Schedule of Benefits Services listed are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details. RW-I, 11/10 MD0000000365
More informationTRADITIONAL PPO PLAN FT. LAUDERDALE $10/20%/40% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC.
TRADITIONAL PPO PLAN FT. LAUDERDALE $10/20%/40% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible
More informationMember s Responsibility: Deductible, Copays, Coinsurance and Maximums
Benefits-at-a-Glance for GradCare 2018 This is intended as an easy-to-read summary. It is not a contract. Refer to the Your Benefits chapter in the Certificate for an official description of benefits.
More informationESSENTIAL ASSIST PPO PLAN (WITH HRA) $10/25%/50% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC.
ESSENTIAL ASSIST PPO PLAN (WITH HRA) $10/25%/50% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JANUARY 1, 2018 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned
More informationWILLIS KNIGHTON MEDICAL CENTER S2763 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Customized COB Dependents Children birth to 26 Filing Limit 12 months For employees that work in a WKHS location within the primary HealthPlus
More informationUNIVERSITY OF THE CUMBERLANDS MEDICAL BENEFITS SCHEDULE
November 1, 2016 UNIVERSITY OF THE CUMBERLANDS MEDICAL BENEFITS SCHEDULE NETWORK NON-NETWORK Lifetime Maximum Benefit Unlimited Unlimited Annual Deductible (Single/Family) $500/$1,000 $1,000/$2,000 Maximum
More informationSchedule of Benefits
3T, 09/09 Schedule of Benefits Services listed below are covered when Medically Necessary. Please see your Benefit Handbook for details. Your Plan offers two levels of coverage: and Out-of-Network. Coverage
More informationHEALTH SAVINGS PPO PLAN (WITH HSA) - BOISE PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE June 1, 2017 AETNA INC. CPOS II
HEALTH SAVINGS PPO PLAN (WITH HSA) - BOISE PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE June 1, 2017 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible -
More informationMERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015
MERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015 DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS facilities and Aligned
More informationHEALTH SAVINGS PPO PLAN (WITH HSA) FT. LAUDERDALE PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JUNE 1, 2017 AETNA INC.
HEALTH SAVINGS PPO PLAN (WITH HSA) FT. LAUDERDALE PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE JUNE 1, 2017 AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS and Aligned Deductible
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $2,500 The maximum out-of-pocket limit applies to all
More informationSummary of Benefits CCPOA (Basic) Custom Access+ HMO
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Primary Care Physician Selection Optional There is no requirement for member pre-certification.
More informationJanuary 1, 2015 December 31, Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
BLUECROSS BLUESHIELD SENIOR BLUE 601 (HMO), BLUECROSS BLUESHIELD SENIOR BLUE HMO SELECT (HMO) AND BLUECROSS BLUESHIELD SENIOR BLUE HMO 651 PARTD (HMO) (a Medicare Advantage Health Maintenance Organization
More informationBenefits are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES Annual Deductible The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Hearing aid reimbursement does not apply to the out-of-pocket
More information2017 Summary of Benefits
H5209 004_DSB9 23 16 File & Use 10/14/2016 DHS Approved 10 7 2016 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP) January 1, 2017 to December
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 informationNY EPO OA 1-09 v Page 1
PLAN FEATURES Deductible (per calendar year) Member Coinsurance (applies to all expenses unless otherwise stated) Maximum Out-of-Pocket Limit (per calendar year) Lifetime Maximum (per member lifetime)
More informationCALIFORNIA Small Group HMO Aetna Health of California, Inc. Plan Effective Date: 04/01/2007. Aetna Value Network* HMO $30/$40
PLAN FEATURES Deductible (per calendar year) Member Coinsurance Lifetime Maximum Primary Care Physician Selection Referral Requirement PHYSICIAN SERVICES CALIFORNIA Small Group HMO Primary Care Physician
More informationBenefits are effective January 01, 2017 through December 31, 2017
Benefits are effective January 01, 2017 through December 31, 2017 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES Network & Out-of- Annual Deductible $0 This is the amount
More informationYour Plan has a $1,000 per Member Deductible and a $2,000 per family Deductible per calendar year.
0D, 07/07 Schedule of Benefits 1000 Services listed below are covered when Medically Necessary and provided or arranged by Harvard Pilgrim Health Care providers. Please see your Benefit Handbook for details.
More informationSummary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network & Out-of- Annual Deductible This is the amount you have to pay out of pocket before the plan will pay
More informationAetna Health of California, Inc.
Easily locate PrimeCare participating providers at www.aetna.com/docfind/primecare PLAN FEATURES Deductible (per calendar year) Member Coinsurance Lifetime Maximum Primary Care Physician Selection Referral
More informationSelect Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2015 - December 31, 2015 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More informationSchedule of Benefits
Schedule of Benefits ANTHEM Small Business Health Options Program (SHOP) This is a brief schedule of benefits. Refer to your Anthem Certificate of Coverage (Booklet) for complete details on benefits, conditions,
More informationYour Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual
More informationYour Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $3,000 single/ 3x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,200 single/ 2x family maximum. With respect to family plans,
More informationCAPE COD MUNICIPAL HEALTH GROUP IMPORTANT - PLEASE READ
CAPE COD MUNICIPAL HEALTH GROUP IMPORTANT - PLEASE READ The attached benefit comparison chart is a high level overview of the plans offered by CCMHG. The plan documents available to registered users on
More information$10 copay. $10 copay. $10 copay $5 copay $10 copay $5 copay. $10 copay. No charge. No charge. No charge
PLAN FEATURES * ** Deductible (per calendar ) Member Coinsurance Copay Maximum (per calendar ) Lifetime Maximum Unlimited Primary Care Physician Selection Required Upon enrollment to a Vitalidad Plus plan,
More informationUnitedHealthcare SignatureValue TM Advantage Offered by UnitedHealthcare of California HMO Schedule of Benefits GOLD ADVANTAGE 0
CALIFORNIA SMALL GROUP UnitedHealthcare SignatureValue TM Advantage Offered by UnitedHealthcare of California HMO Schedule of Benefits GOLD ADVANTAGE 0 These services are covered as indicated when authorized
More informationSchedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM TIERED COPAYMENT HMO MASSACHUSETTS
Schedule of Benefits Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM TIERED COPAYMENT HMO MASSACHUSETTS ID: MD0000002776 CODE: 8-SOF DATE: 06/01/2012 This Schedule of Benefits summarizes your Benefits
More informationINTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS
INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California: Fresno, Merced, Stanislaus and San Joaquin Counties H5928_15_029_SB_CTCA_2
More informationSchedule of Benefits
SN, 10/09 Schedule of Benefits Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. Your Plan offers two levels of coverage: and. Coverage coverage applies
More informationMedicare Plus Blue SM Group PPO. Summary of Benefits. Michigan Public School Employees Retirement System
2018 Medicare Plus Blue SM Group Summary of Benefits January 1, 2018 December 31, 2018 Michigan Public School Employees Retirement System www.bcbsm.com/mpsers This information is a summary document and
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Jade (HMO SNP) Kern, Los Angeles and Orange counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0175 CMS Accepted 09082015
More informationCLASSIC BLUE SECURE/BLUE CROSS BLUE SHIELD COMPLEMENTARY Monroe County Benefit Summary/Comparison (Over 65 Retirees)
WHO IS COVERED Enrollment Requirement Members must be enrolled in both Medicare Parts A and B Members must be enrolled in both Medicare Parts A and B Type of Tier Single only Single only Dependent/Student
More informationCentral Care Plan Medical and Prescription Plan Comparison Grid
Medical Plan Carrier/Network Annual Deductible (Benefit Plan Year: 7/1-6/30) Coinsurance (Percent Copays) Note: Coinsurance s apply once the has been met. Flat Dollar Copays Central Care Plan $200 per
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/0% These services are covered as indicated when authorized through your Primary Care
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO 20 (20/0%) EFFECTIVE JULY 1, 2017 These services are covered as indicated when authorized through your Primary Care Physician
More informationCentral Care Plan Medical and Prescription Plan Comparison Grid
Medical Plan Carrier/Network Annual Deductible (Benefit Plan Year: 7/1 6/30) Coinsurance (Percent Copays) Note: Coinsurance amounts apply once the has been met. Flat Dollar Copays $400 per member $800
More informationCITY OF SLIDELL S2630 NON-GRANDFATHERED BENEFIT SHEET
CITY OF SLIDELL S2630 BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 No later than 365 days after the Filing Limit date expenses are incurred
More informationStanislaus County Medical Benefits EPO Option. In-Network Benefits (Stanislaus County Partners in Out-of-Network Benefits
Stanislaus County Medical EPO Option The following summary of benefits is a brief outline of the maximum amounts or special limits that may apply to benefits payable under the Plan. For a detailed description
More informationTelemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Benefit Package B, Network 2) 20/500A These services are covered
More informationST. MARY S HEALTHCARE SYSTEM, INC. Case # GA6476 BlueChoice HMO Benefit Summary Effective: January 1, 2018
ST. MARY S HEALTHCARE SYSTEM, INC. Case # GA6476 BlueChoice HMO Benefit Summary Effective: January 1, 2018 All benefits are subject to the calendar year deductible, except those with in-network copayments,
More informationSUMMARY OF P-5-5 BENEFITS AND SCHEDULE OF COPAYMENTS
SUMMARY OF P-5-5 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 BE
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/250A These services are covered as indicated when authorized through your
More informationHMO Basic (HMO) / HMO 40 (HMO) / HMO 20 (HMO) Summary of Benefits
/ / Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-800-965-4022 8 a.m. to 8 p.m. daily October 1 to February 15 and 8 a.m. to 8 p.m. weekdays the rest of the year. TTY/TDD 711 HealthAllianceMedicare.org
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
More information2018 Summary of Benefits
2018 Summary of Benefits H5209-004_MDASB 9-13-17 Accepted 9/18/2018 DHS Approved 09/13/2017 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP)
More informationSummary of Benefits 2018
SM Summary of Benefits 2018 bluecareplus.bcbst.com H3259_18_SB Accepted 08282017 This is a summary of drug and health services covered by BlueCare Plus (HMO SNP) SM health plan January 1, 2018 - December
More informationUnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
More informationSummary of Benefits Prominence Preferred Health Insurance Small Group Health Plan
Calendar Year Deductible (CYD) 2 $1,000 Single / $3,000 Family $3,000 Single / $9,000 Family Coinsurance - Member responsibility 20% coinsurance 50% coinsurance Out-of-Pocket Maximum 3 - Deductibles, coinsurance
More informationSummary of Benefits for Anthem MediBlue Dual Advantage (HMO SNP)
Summary of Benefits for Available in: Select Counties* in Maine *See Page 2 for a list of counties. Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits
More informationBCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
Michigan Catholic Conference Group Number: 71755 Package Code(s): 010 Section Code(s): 1000, 2000 PPO - PPO1, Hearing, Vision ( Exam only) Effective Date: 01/01/2018 Benefits-at-a-glance This is intended
More informationFLEX RETIREE MAP (Over 65 Flex Retirees) 2018 Benefits PROFESSIONAL SERVICES. Visit to a physician, physician assistant or nurse practitioner at a PPG
PROFESSIONAL SERVICES Visit to a physician, physician assistant or nurse practitioner at a PPG Periodic health evaluations/preventive services - Applies when the only service(s) provided is a Medicare
More informationNEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS
XV-2 $30/$60/$200/$1,000/80% R NEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the Point of Service (POS) Plan you have with Neighborhood
More informationSUMMARY OF BENEFITS. Hamilton County Department of Education Network Copay Plan. Connecticut General Life Insurance Co.
SUMMARY OF BENEFITS Connecticut General Life Insurance Co. Hamilton County Department of Education Annual deductibles and maximums Lifetime maximum Pre-Existing Condition Limitation (PCL) Coinsurance All
More informationBlue Cross Premier Bronze
An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within BCBSM s unsurpassed statewide PPO network including nationwide coverage.
More informationUNIVERSITY OF MICHIGAN BZK Effective Date: 01/01/2018
UNIVERSITY OF MICHIGAN 68712000 0070051870000-06BZK Effective Date: 01/01/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Senior Care Options (HMO SNP) H2226-001 Look inside to learn more about the plan and the health and drug services it covers. Call Customer
More informationSummary of Benefits Prominence HealthFirst Small Group Health Plan
POS Triple Choice 3000 Summary of Benefits Calendar Year Deductible (CYD) $3,000 Single / $9,000 Family $7,000 Single / $21,000 Family $21,000 Single / $63,000 Family Coinsurance 40% coinsurance 50% coinsurance
More informationCorrection Notice. Health Partners Medicare Special Plan
Correction Notice Special Plan Following are corrections that apply to both the English and Spanish versions of the 2015 for Special (HMO SNP): Original Information Page 1, under the heading SECTIONS IN
More informationSuper Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Deductible
BENEFIT HIGHLIGHTS 1 Super Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Group Effective Date December 1, 2017 Benefit Period (used for and Coinsurance limits) January 1 through December
More informationPLAN DESIGN AND BENEFITS - PA POS 4.2 with $5/$15/$30 RX PARTICIPATING PROVIDERS
PLAN FEATURES Deductible (per calendar year) PHYSICIAN SERVICES Primary Care Physician Visits Specialist Office Visits Maternity OB Visits Allergy Treatment Allergy Testing PREVENTIVE CARE Routine Adult
More informationSignal Advantage HMO (HMO) Summary of Benefits
Signal Advantage HMO (HMO) Summary of Benefits January 1, 2016 December 31, 2016 The provider network may change at any time. You will receive notice when necessary. This information is available for free
More informationKaiser Permanente Group Plan 301 Benefit and Payment Chart
301 Kaiser Permanente Group Plan 301 Benefit and Payment Chart 10119 CITY AND COUNTY OF SAN FRANCISCO About this chart This benefit and payment chart: Is a summary of covered services and other benefits.
More informationSUMMARY OF BENEFITS. Cigna-HealthSpring. Advantage SMS (HMO) H January 1, December 31, Cigna H4407_16_32690 Accepted
SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Advantage SMS (HMO) H4407-011 2015 Cigna H4407_16_32690 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet
More informationSummary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx] Group Plan HMO Benefit
More informationHEALTH PLAN BENEFITS AND COVERAGE MATRIX
HEALTH PLAN BENEFITS AND COVERAGE MATRIX 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 BE CONSULTED FOR
More informationSummary of Benefits Platinum Full PPO 0/10 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Full PPO 0/10 OffEx Group Plan PPO Benefit Plan This Summary of Benefits shows the amount
More informationSchedule of Benefits - Indemnity Group - MEDFORD AREA SCHOOL DISTRICT Benefit Year: January 1st through December 31st Effective Date: 01/01/2016
Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits as of the effective date shown on the letter you received with
More informationSummary of Benefits Platinum Trio HMO 0/25 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Trio HMO 0/25 OffEx Group Plan HMO Benefit Plan This Summary of Benefits shows the amount
More informationCCMHG Health Deductible Plan Benefit Comparison - FY18
Deductible - applies to: In-patient Admission; Out-patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) and Diagnostic Tests & Procedures. Does not apply to routine office visits or pharmacy. Per plan
More informationSUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. For Employees of - Digital Risk, LLC Open Access Plus Plan
SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. For Employees of - Digital Risk, LLC Open Access Plus Plan Notice of Grandfathered Plan Status This plan is being treated as a "grandfathered health
More informationSENIOR MED, LLC EMPLOYEE BENEFIT PLAN MEDICAL BENEFITS SCHEDULE LOW PLAN Effective April 1, 2014
LOW PLAN MAXIMUM BENEFIT AMOUNT: Aggregate Annual Limit NETWORK PROVIDERS NOTE: Benefits are only covered at Network Providers. No coverage is available at NON-NETWORK Providers, except where indicated
More informationBENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company
Appendix A BENEFIT PLAN Prepared Exclusively for The Dow Chemical Company What Your Plan Covers and How Benefits are Paid Traditional Choice (Over Age 65 Retirees - Comprehensive Medical MAP Plus Option
More informationIllustrative Benefits, Value Added Services and Premiums are effective January 1, 2016 through December 31, 2016
PLAN FEATURES Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) Network & Out-of-Network Providers $0 Member Coinsurance N/A Applies to all expenses unless otherwise stated.
More informationUnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California HMO Deductible Schedule of Benefits HRA-QUALIFIED DEDUCTIBLE HEALTH PLAN 35-50/20%/2000DED
More informationBlue Cross provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
HOPE COLLEGE - HOURLY ORANGE 007013084/0011/0012/0013/0014/0015/0016/0017 Simply Blue PPO HSA ASC Effective Date: On or after July 2018 Benefits-at-a-glance This is intended as an easy-to-read summary
More informationBenefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN FEATURES Network & Out-of- Annual Deductible This is the amount you have to pay out of pocket before the plan will pay
More informationExtra Value Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2016 - December 31, 2016 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More information