HEALTH SAVINGS ACCOUNT (HSA)
|
|
- Derick Edwards
- 5 years ago
- Views:
Transcription
1 HSA FEATURES Health Savings Account Amount $600 Employee $1,000 Family Amount contributed to the HSA by the employer. Funded on a quarterly basis. HSA amount reflected is on a per calendar year basis. The HSA received may be prorated based on your effective date of coverage. Maximum Contribution $3,300 Employee $6,550 Family The combined maximum that you and your employer can contirbute. You can contribute up to the maximum allowable limit on a pre-tax basis through payroll deduction OR by making a deposit to your HSA through the PayFlex site. Employee Termination from Aetna Health Savings HSA Rollover Annual Maximum Rollover HSA is yours, which means if you change employers or leave the work force, the HSA stays with you. Any remaining HSA benefit amount at end of plan year is rolled over into next years HSA benefit amount. No maximum rollover applies. All remaining funds at plan year end rollover. Cumulative Maximum Rollover No maximum rollover applies. All remaining funds rollover. Eligible HSA Expenses Member may use HSA dollars towards eligible Medical, Pharmacy, Dental and Vision expenses. Or deposit in a mutual fund for longterm savings HSA Payment/Assignment Network Providers: Member may assign payment to provider. Non-Network Providers: Member may assign payment to provider. Pro-ration for New Employees Pro-ration for Family Status Change Quarterly No pro-ration. Change to new tier based on new employee status. PLAN FEATURES Deductible (per calendar year) $1,300 Employee $1,300 Employee $2,500 Family $2,500 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. Plan Coinsurance Applies to all expenses unless otherwise stated. Member Payment Limit 80% $2,000 Employee 60% $2,000 Employee (per calendar year) $4,000 Family $4,000 Family Includes Deductible All covered expenses, including prescription drugs after has been met, accumulate toward both the preferred and non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, s, and prescription drug copays (except any penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum Primary Care Physician Selection Unlimited except where otherwise Optional Unlimited except where otherwise Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Referral Requirement None None Page 1
2 PREVENTIVE CARE Routine Adult Physical Exams/ Immunizations 1 exam per 12 months Routine Well Child Exams/Immunizations 7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam per 12 months thereafter to age 18 Routine Gynecological Care Exams Includes routine tests and related lab fees; 1 exam per calendar year Routine Mammograms 1 baseline mammogram at age 35. One mammogram per calendar year thereafter Women's Health Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostatespecific Antigen Test For covered males age 40 and over; 1 exam per calendar year Colorectal Cancer Screening (no age or frequency limitation) Routine Hearing Exams 1 routine exam per 24 months Hearing Aids Limited to $600 per calendar year PHYSICIAN SERVICES Office Visits to PCP Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits Pre-Natal Maternity Maternity Delivery and Post Partum Care Hearing Exams 1 routine exam per 24 months Hearing Aids Limited to $600 per calendar year Allergy Testing Allergy Injections DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-ray If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing Diagnostic X-ray for Complex Imaging Services EMERGENCY MEDICAL CARE Urgent Care Provider Non-Urgent Use of Urgent Care Provider Emergency Room Not Covered Not Covered Non-Emergency care in an Emergency Room 50% after 50% after Page 2
3 Ambulance HOSPITAL CARE Inpatient Coverage Stantec Consulting Services and Affillated Companies Inpatient Maternity Coverage Outpatient Surgery Outpatient Hospital Expenses (excluding surgery) The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES Inpatient Outpatient The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES Inpatient Outpatient The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit OTHER SERVICES Convalescent Facility Limited to 120 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient Hospice Care - Outpatient The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Private Duty Nursing - Outpatient (Limited to 70 eight hour shifts per calendar year) Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift. Each visiting nurse care or private duty nursing care shift of 4 hours or less counts as one home health visit. Each such shift of over 4 hours and up to 8 hours counts as two home health care visits. Outpatient Short-Term Rehabilitation Includes Physical Therapy limited to 60 visits per plan year; Speech and Occupation Therapy unlimited visits per plan year; Subject to medical necessity Spinal Manipulation Therapy Limited to 20 visits per calendar year; not subject to medical necessity Acupuncture Therapy Limited to 10 visits per calendar year Durable Medical Equipment Includes foot orthotics and supportive devices for the feet. Diabetic Supplies Generic FDA-approved Women s Contraceptives Contraceptive drugs and devices not obtainable at a pharmacy (includes coverage for contraceptive visits) 80% (payable as any other covered expense) after 60% (payable as any other covered expense) after Page 3
4 Transplants Mouth, Jaws and Teeth (oral surgery procedures, medical in nature) Out of Area Dependents FAMILY PLANNING Infertility Treatment Stantec Consulting Services and Affillated Companies 80% Preferred coverage is provided 60% Non-Preferred coverage is at an IOE contracted facility only; after provided at a Non-IOE facility; after Coverage provided at the non-preferred benefit level of the plan; after Diagnosis and treatment of the underlying medical condition. Vasectomy Tubal Ligation PHARMACY The full cost of the drug is applied to the before benefits are considered for payment under the pharmacy plan. Retail $5 copay for generic drugs, $30 copay 60% of submitted cost after $5 copay for formulary brand-name drugs, and for generic drugs, $30 copay for $60 copay for non-formulary brandname formulary brand-name drugs, and $60 drugs up to a 30 day supply at copay for non-formulary brand-name participating pharmacies. drugs up to a 30 day supply. Mail Order - mandatory mail order for maintenance medications. Get up to 2 fills at a retail pharmacy. After that, you must use Aetna Rx Home Delivery or a CVS retail pharmacy. $10 copay for generic drugs, $60 copay for formulary brand-name drugs, and $120 copay for nonformulary brand-name drugs up to a day supply from Aetna Rx Home Delivery or Retail CVS Location Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator or from your employer. Copays paid by the Fund for these drugs will not reduce the. Pharmacy Managed Self Injectables (PMSI) First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy Choose Generic with DAW Override- the member pays the applicable out of pocket cost. If the physician requires brand, member would pay brand name out of pocket cost. If the member requests brand-name when a generic is available, the member pays the applicable out of pocket cost plus the difference between the generic price and the brand-name price. Formulary generic FDA-approved Women s Contraceptives covered 100% in network. GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 Pre-existing Conditions Exclusion On effective date: Waived Not applicable Plan Includes: Contraceptive drugs and devices obtainable from a pharmacy, Diabetic supplies. Smoking cessation aids Precert for growth hormones included. Page 4
5 This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. Page 5
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
More informationOptional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived 30% after deductible
PLAN FEATURES NON- Deductible (per calendar year) $500 Individual $750 Individual $1,500 Family $2,250 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and
More informationOptional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
More informationPLAN FEATURES PREFERRED CARE
PLAN DESIGN & BENEFITS - "HMO" PLAN FEATURES Deductible (per calendar year) $200 Individual $400 Family All covered expenses, excluding prescription drugs, accumulate toward the preferred Deductible. Unless
More informationPREFERRED CARE. combination of family members; however no single individual within the family will be subject to more than the individual
PLAN FEATURES Deductible (per plan year) $500 Individual $1,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The family Deductible is a cumulative Deductible
More informationUpdated: 10/01/12 Page : 1
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family
More informationHigh Deductible Health Plan - H S A PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES NON- Deductible (per calendar year) $1,300 Individual $2,000 Individual $2,600 Family $4,000 Family All covered expenses including prescription drugs accumulate toward both the preferred
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $250 Individual None Family $750 Family Unless otherwise indicated, the deductible must be met prior to benefits being
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 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 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 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 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 informationOpen Access PLAN DESIGN
PLAN FEATURES Deductible (per plan year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family All covered expenses accumulate separately toward preferred or non-preferred Deductible. Unlesss
More information$2,000 Individual. Deductible (per calendar year)
PLAN FEATURES Deductible (per calendar year) FAMILY PHYSICIANS GROUP $2,000 Individual $4,000 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost
More informationPLAN DESIGN & BENEFITS
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) Poway Unified School District None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include
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 informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA
PLAN FEATURES Deductible (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met
More informationHealth Reimbursement Account and Health Savings Account
Plan Design & Benefits 1 EFFECTIVE JANUARY 1, 2011 Health Reimbursement Account and Health Savings Account Employee: $1,000 Employee + spouse: $1,500 Employee + children: $1,500 Family: $2,000 Non- Employee:
More informationKaiser Permanente (No. and So. California) 2018 Union
Kaiser Permanente (No. and So. California) General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Precertification Penalty Health Savings
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 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 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 informationAETNA PPO PLAN COVERED DEPENDENTS UNDER 65
AETNA PPO PLAN COVERED DEPENDENTS UNDER 65 Plan Deductible (per calendar year; applies to all covered services; excludes deductible carryover.) $300 Individual $600 Family $600 Individual $1200 Family
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 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 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 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 informationThe MITRE Corporation Plan
Benefit Type Plan Year Type Calendar Year Annual Medical Out of (for certain services) Employee Employee + 1 Family Annual Prescription Drug Out of Employee Employee + 1 Family Copayments: One copay per
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 informationFCPS BENEFITS COMPARISON FOR PLAN YEAR 2018 Active Employees and Retirees Under 65
BENEFIT Medical Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Individual Annual Deductible $250 $500 $250 $500 None Family Annual Deductible $500 $1,000 $500 $1,000 None Medical Plan
More informationCigna Summary of Benefits Open Access Plus Copay Plan (OAP10)
Cigna Care Network (CCN) Cigna Summary of Benefits Open Access Plus Copay Plan (OAP10) Cigna Care Network (CCN) Your employer has selected a Cigna Care Network (CCN) plan. When you need specialty care,
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 informationRSNA EMPLOYEE BENEFIT TRUST PLAN II S2502 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to age 26 Filing Limit 1 year from date of service Mailing Address & PPO Company. Remit claims to:
More informationSCHEDULE OF MEDICAL BENEFITS
Annual Deductibles Annual Out-of-Pocket Maximums Inpatient Hospital Copayment (Excludes Deductible) $250 Individual $1,000 Individual $100 per day, not to exceed $500 Family $2,000 Family $600 per admission
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 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 informationBenefits at a Glance. Vectrus Systems Corporation Policy Number: 04804A. OAP Global Plan
Benefits at a Glance Vectrus Systems Corporation Policy Number: 04804A OAP Global Plan Vectrus Systems Corporation Long Benefits at a Glance Policy # 04804A Effective Date January 1, 2016 Vectrus Systems
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 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 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 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 informationBlue Choice. Hospital/$50, Physician's Office/Lesser of $50 or 20%; physician $40, facility $50. $35/trip $100/trip $50/trip $100/trip $100/trip
HOSPITAL SERVICES Hospital Inpatient : Paid in full No cost No cost No cost No cost Hospital Outpatient Hospital $40 or $60 per visit, : $20 per visit Hospital/$50, Physician's Office/Lesser of $50 or
More informationHOME BANK - S2395 NON-GRANDFATHERED CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET
CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 180 days from incurred Filing Limit date, except when 180 days would
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 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 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 informationSkilled nursing facility visits
Modified Premier HMO 20 Non Union This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits in your plan, please refer to your Certificate
More informationState of New Jersey Aetna Medicare SM Plan (PPO)
PLAN FEATURES Deductible (per calendar year) Network Providers $0 Deductible Member Coinsurance N/A Applies to all expenses unless otherwise stated. Annual Maximum Out-of- $1,000 Pocket Amount (includes
More informationCONRAD INDUSTRIES, INC. S2489 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children to age 26 Filing Limit 12 months from date of service Mailing Address & PPO Company. PPO Co.: PPO CIGNA
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 information2016 Medical Plan Comparison Chart
2016 Medical Plan Comparison Chart WellStar Health System is committed to helping you control healthcare costs while providing more choices and personal control over your healthcare coverage through the
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 informationAetna Open Access POS II
Aetna Open Access POS II The Aetna Open Access Point-of-Service (POS) II Options combine the advantages of managed healthcare with the freedom of traditional medical coverage. With the POS options, every
More informationAnthem Blue Cross Effective: January 1, 2018 Your Plan: University of California CORE Plan Your Network: Anthem Prudent Buyer PPO
Anthem Blue Cross Effective: January 1, 2018 Your Plan: University of California CORE Plan Your Network: This summary of benefits is a brief outline of coverage, designed to help you with the selection
More informationPlan Overview. Health Net Platinum 90 HSP. Benefit description Member(s) responsibility 1,2
PureCare HSP is available through Covered CA in Kings, Madera, Sacramento, and Yolo counties, and parts of El Dorado, Fresno, Nevada, Placer, and Santa Clara counties. Plan Overview Health Net Platinum
More informationKaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION
Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION 2019 Summary of Important Changes for Contract Renewals for the Kaiser Permanente Group Plan (These changes are subject to regulatory
More informationExcellus Blue PPO Signature Hybrid 1
Excellus Blue PPO Signature Hybrid 1 Drug Coverage Excluded Benefit Time Period: 03/01/2018-12/31/2018 Trinity Health - Syracuse Traditional General Cost Sharing Expenses Deductible - Single $250 $750
More informationRegence Engage Plan Highlights For Groups of /1/2016
Plan Features Provider choice: Members have direct access to their choice of providers. Category 1 are Preferred; Category 2 are Participating; and Category 3 are Non-contracted providers. Simplicity:
More informationExcellus BluePPO Signature Deduct 3
Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 03/01/2018-12/31/2018 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single $1,500 $2,500 $3,500 - Two Person
More informationHighlights of your Health Care Coverage
Highlights of your Health Care Coverage Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is
More information$25 copay per visit annual deductible applies. $30 copay per visit annual deductible applies
Minnesota Public Employees Insurance Program (PEIP) Advantage Health Plan 2018-2019 Benefits Schedule Benefit Provision Cost Level 1 You Pay Cost Level 2 You Pay Cost Level 3 You Pay Cost Level 4 You Pay
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 informationGLOBAL HEALTH ADVANTAGE 2 to 20
GLOBAL HEALTH ADVANTAGE 2 to 20 Benefits Proposal Prepared specially for Marathon Petroleum Effective Date: 01/01/2018 112336 8/17 Offered by: Cigna Health and Life Insurance Company, Connecticut General
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 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 informationProvider Guide for Prime Healthcare EPO
Provider Guide for Prime Healthcare EPO Revised: 02012014 Page 1 Table of Contents INTRODUCTION... 3 OVERVIEW... 3 BENEFIT AND REIMBURSEMENT... 3 PLAN PARTICIPATION... 4 UTILIZATION MANAGEMENT AND REFERRAL
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 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 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 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 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 informationGold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix)
Gold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED
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 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 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 informationPage 1 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 SUMMARY OF HEALTH PLAN BENEFITS
Page 1 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Hospital Room Services Hospital Outpatient Surgery Maternity Skilled Nursing Facility Lab, Xray and Diagnostic Testing Home Health Care Mental
More informationPlatinum Local Access+ HMO $25 OffEx
Platinum Local Access+ HMO $25 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED
More informationBlue Shield High Deductible Plan
Blue Shield High Deductible Plan Benefit Booklet Stanford University Group Number: 170293, 976184 & 976185 Effective Date: January 1, 2014 An independent member of the Blue Shield Association Claims Administered
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 informationSUMMARY OF BENEFITS. Your Valley Health System Network and CIGNA HealthCare Open Access Plus In-Network plan
SUMMARY OF BENEFITS Your Valley Health System Network and CIGNA HealthCare Open Access Plus In-Network plan Features that Add Value Your plan offers the convenience of referral-free access to doctors,
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 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 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 information2017 Comparison of the State of Iowa Medicaid Enterprise Basic Benefits Based on Eligibility Determination
General Plan Provisions Benefits Available from Out-of-Network Providers 2017 Comparison of the State of Iowa Enterprise Cost Sharing: A variety of methods are used to share expenses between the state
More informationBlue Shield of California
An independent member of the Blue Shield Association City of San Jose Custom ASO PPO 100 90/70 Active Employees Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage
More informationEXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan
2018 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare
More informationChapter 12 Benefits and Covered Services
12 Benefits and Covered Services Health Choice Generations covers the same benefits covered under Original Medicare. Sometimes Medicare adds coverage for a new service during the year. Health Choice Generations
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 informationAetna Fixed Indemnity Plan Helps pay for the costs of everyday medical expenses
Aetna Fixed Indemnity Plan Helps pay for the costs of everyday medical expenses Extra benefits when you need them Do you have security in knowing you have help handling your medical expenses? You can with
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 informationExcellus BluePPO Option K
Excellus BluePPO Option K Contraceptives Only Benefit Time Period: 01/01/2018-12/31/2018 NYS Automobile Dealers Assoc. General Information Cost Sharing Expenses Deductible - Single $0 $1,000 Deductible
More informationAmherst Central School District First Choice Health Plan. Non-First Choice Providers and Out-of-Network Providers
Health: Hospital Services provided by First Choice Preferred Provider Network Medical Services Radiology, Ultrasounds 20% after $500 individual or Laboratory Testing 20% after $500 individual or MRI and
More informationUNM Medical Plan. summary of benefits. Effective: July 1, 2012
UNM Medical Plan summary of benefits Effective: July 1, 2012 Offered by The Regents of the University of New Mexico Administered by Lovelace Insurance Company administered by ANNUAL PLAN YEAR DEDUCTIBLE
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 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 informationHigh Deductible Health Plan (HDHP)
High Deductible Health Plan (HDHP) BeneFIts Summary Effective July 1, 2012 or October 1, 2012 Benefit Highlights How The Plan Works...1 Summary Of Benefits...4 Special Programs...7 Approval Of Care At
More informationCigna Health and Life Insurance Company. Plan Benefits. Unlimited. Unlimited. Not applicable. Not applicable. Not applicable
SUMMARY OF BENEFITS Client Name: Washington County Public Schools Benefit Option Name: Medicare Supplement Effective: July 1, 2018 through June 30, 2019 1 Benefit Description Lifetime Maximum Applies to
More information