CITY OF SLIDELL S2630 NON-GRANDFATHERED BENEFIT SHEET
|
|
- Lindsey Eaton
- 5 years ago
- Views:
Transcription
1 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 Mailing Address & Company. Remit claims to: CIGNA Physicians & Hospitals & Non: Mail claims to Cigna, P.O. Box Chattanooga, TN Electronic Payer ID Certain Cigna Ancillary Providers are required to file claims to the Ancillary Vendor Network If members access a Third Party Network will have remit info as follows (and reflected on ID cards): Community Health Network Cigna Mt-CHN P.O. Box 3018 Missoula, MT EDI# Mississippi Health Partners MHP Systems P.O. Box Jackson, MS EDI# Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing. The following facilities appear as in error on the Cigna.com website and should be excluded from Cigna as they are not participating providers for payer solution groups: - Baptist Memorial Hospital Memphis - Baptist Memorial Hospital for Women - Baptist Memorial Restorative Care Hospital - Baptist Memorial Hospital Collierville - Baptist Memorial Hospital Desoto - Baptist Memorial Hospital Tipton - Baptist Rehabilitation Hospital Germantown Pre-Existing Does not apply Utilization Review: Cigna Must precertify services listed 2 days prior to admission, Emergency admissions within 48 hours or 2 business days. Inpatient confinements*, All transplant procedures Penalty: Additional $100 *Precertification is not required for inpatient or outpatient Lab Band/Lap Sleeve surgical procedures; however, complications from Lap Band/Lap Sleeve surgical procedures will be treated as any other illness, so an inpatient admission resulting from such complications will require precertification. NOTE: Occupational Therapy, Physical Therapy and Vision Therapy visits over 20 may be covered if precertification is obtained through MedCom ( ) Provider must send Letter of Medical Necessity & all applicable notes). Pre-cert penalty does not apply. Precert for PT/OT/VT only must be obtained through MedCom. GILSBARDM-# v37-Document.doc Page 1 of 8
2 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION PLAN YEAR MAXIMUM BENEFIT DEDUCTIBLE, PER PLAN YEAR NON- Unlimited Expenses applied toward the satisfaction of the amount will not be applied toward satisfaction of the Non-, and expenses applied toward the satisfaction of the Non- amount will not be applied toward satisfaction of the. Per Participant $1,500 $3,000 Per Family $3,000 $6,000 MAXIMUM OUT-OF-POCKET EXPENSES, PER PLAN YEAR Expenses applied toward the satisfaction of the out-of-pocket amount will not be applied toward satisfaction of the Non- out-of-pocket, and expenses applied toward the satisfaction of the Non- out-of-pocket amount will not be applied toward satisfaction of the out-of-pocket. Per Participant $3,500 $5,000 Per Family $7,000 $10,000 NOTE: The following charges do not apply toward the out-of-pocket expense and are never paid at 100%: N/A HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture (20 visits Plan Year maximum) Ambulance Ground ambulance Air or water ambulance Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Chemotherapy & Radiation Therapy Chiropractic Treatment Clinical Trials (as defined by this Plan for cancer or other life-threatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the provider. The Plan will cover Non- providers outside the state in which the qualified individual resides only if there is not a provider conducting the same trial in state. Compression Stockings (2 per Plan Year maximum) Dental Impacted Wisdom Teeth (Covered under Medical) $40 $50 $150 : $250 per admission, then 80% after $50 $150 $250 per admission, then 60% after SMH Facility: Not Available 100%, Refer to Non-Surgical Treatment of the Spine Covered under Separate Dental Plan GILSBARDM-# v37-Document.doc Page 2 of 8
3 BENEFIT DESCRIPTION Diabetes Self-management Training Diabetic Nutritional Therapy CITY OF SLIDELL S2630 Diabetic Supplies (Limited to test strips, lancets, alcohol pads and control solutions) Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Inpatient Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Outpatient Hospital Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) Low Tech X-ray and Lab Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Stand Alone Facility Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) Low Tech X-ray and Lab 90%, 100%, $100 $50 $100 $50 NON- Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Office Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) a $100 All other Low tech x-ray (not included in the above) and lab PCP Specialist Durable Medical Equipment Emergency Room Copay if admitted directly to Hospital from Emergency room Accident-related services Non-Accident services a $30 a $40 80%, $100 $150 $100 $150 GILSBARDM-# v37-Document.doc Page 3 of 8
4 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION Extended Care/Skilled Nursing Facility (60 days Plan Year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids (Limited to children up to age 18) ($1,400 per ear once every 3 Plan Years) Cochlear implants are not covered. Hearing Screening Home Health Care Hospice Care Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only or if a semi-private room is not available, 90% of the average private room rate. ICU as billed, Hospital / Facility- Outpatient Outpatient Surgery All other services (Except Advanced imaging, Lab, and X-Ray) Infertility/Sterility : 80%, SMH Facility: NON- Refer to Lap Band/Lap Sleeve 100%. Deductible Refer to Preventive Care Benefit : $250 per admission, then 80% after SMH Facility: $100 per admission, then $250, per admission, then 60% after $100 GILSBARDM-# v37-Document.doc Page 4 of 8
5 BENEFIT DESCRIPTION CITY OF SLIDELL S2630 Lap Band/Lap Sleeve (Limited to Eligible Employees & Eligible Retirees) (Precertification is not required for inpatient or outpatient Lap Band/Lap Sleeve surgical procedures) NON- Initial visit, screening and blood tests Psychiatric evaluation Pre-surgery Surgery (Facility fee) Surgery (Physician s fee) Post-surgery follow-up and adjustments For complications of Lap Band/Lap Sleeve surgical procedures, see applicable services for benefits. Maternity Maternity related expenses for dependent children are not covered, except as required by federal law. Prenatal care as required by federal law Other Office Services Other eligible charges $30 $50 $40 $100 $ %, Refer to Preventive Care 100% no Refer to applicable service for benefits Refer to Preventive Care Refer to applicable service for benefits. Newborn Care (routine inpatient) (Coverage includes circumcisions) Non-Surgical Treatment of the Spine (20 visits Plan Year maximum) (OV & X-ray not included in the Plan Year maximum) Obesity Limited to non-surgical treatment for obesity. Refer to Lap Band/Lap Sleeve for surgical benefits. Refer to plan document for further limitations & exclusions. Oncotype DX Covered at Genomic Health Facility only. Further limited to procedure codes and Organ Transplants Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. Refer to plan document for limitations & exclusions. Orthotics / Prosthetics (Foot orthotics are not covered) Physician Services- Inpatient Visits Physician Services- Inpatient Surgeon $40 $40, then GILSBARDM-# v37-Document.doc Page 5 of 8
6 BENEFIT DESCRIPTION CITY OF SLIDELL S2630 Physician Services- Outpatient Visits (services other than in a Physician s office) Physician Services- Outpatient Surgeon (services other than in a Physician s office) Physician Services: Office Visits Copay is per provider and applies only to the following: office visit charge, inoffice vasectomies, lab and low-tech x-ray, injections, supplies, minor office surgery, and allergy treatment. Additional will apply to Advanced imaging services. Refer to Diagnostic Testing benefits. Primary Care Physician Specialist Allergy Testing $30 $40 NON- All other eligible expenses rendered in the physician s office not covered under. PCP is defined as: Family Practitioner, General Practitioner, Nurse Practitioner, Internist, OB/GYN, Pediatrician and Physician Assistant. Physician Services- In-office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Refer to Physician Services: Office Visits Refer to Physician Services: Office Visits Refer to Hospital / Facility Inpatient Refer to Prescription Drug Benefits schedule and section GILSBARDM-# v37-Document.doc Page 6 of 8
7 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION Preventive Care Benefit Evidence-based items or services with an A or B rating recommended by the United States Preventive Task Force; Immunizations for routine use in children, adolescents, or adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; these can be done at the pharmacy (refer also to Prescription Drug Benefits schedule and section) Evidence-informed preventive care and screening provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents; and Other evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA for women. Routine physical exam (1 per Plan Year), including related diagnostic tests performed during the same visit. Routine lab work All immunizations, including HPV Vaccine, covered per CDC Guidelines Gynecological exam and pap smear (1 per Plan Year) One prostatic/testicular exam & PSA for insureds 50 years of age or older, or as recommended by the Physician if the insured is 40 years of age or older Colon exam Hearing screening (1per Plan Year) Mammogram 1 per Plan year Colorectal screening routine cancer screen shall mean a fecal occult blood test, flexible sigmoidoscopy or colonoscopy as provided in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for ages, family histories, and frequencies referenced in such recommendations. Routine colorectal cancer screening shall not mean services otherwise excluded from benefits because the services are deemed by the Plan Administration to be investigational or experimental NON- 100% no Breast pumps are l limited to one per Plan Year Private Duty Nursing (Limited to Outpatient only and 60 visits Plan Year maximum) Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac Rehab limited to phases I & II. Limited to 36 visits per Plan Year. Additional visits may be covered if precertification is obtained through MedCom ( ) Occupational Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( ) Physical Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( Speech Therapy 20 visits Plan Year maximum. Includes services for speech loss and developmental delays. Vision Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( Sleep Disorders Covered only if medically necessary Sleep Study Other eligible expenses Smoking Cessation $30 Refer to applicable service for benefits Refer to applicable service for benefits 100%, GILSBARDM-# v37-Document.doc Page 7 of 8
8 BENEFIT DESCRIPTION Sterilization CITY OF SLIDELL S2630. NON- Vasectomy (See Physician Services: Office Visits for services performed in the office) Refer to Preventive Refer to Care Female Sterilization as required by federal law Preventive Care Temporomandibular Joint Syndrome Urgent Care Facility (includes all covered charges billed by facility, except advanced imaging) $30 $30 (Additional will apply to Advanced imaging services. Refer to Diagnostic Testing benefits.) Vision Exam (1 per Plan Year maximum) $40 $40 Frames, glasses and contacts are not covered. Wig After Chemotherapy ($500 Lifetime maximum) PRESCRIPTION DRUG CARD OPTION Pharmacy Benefits Manager: PBI/Caremark. Prescription Drug Deductible Deductible must be satisfied before benefits will be paid; Deductible is for Generics and Prescribed Preventive Medications and Contraceptives as required by federal law. Per Participant, per Plan Year $50 Per Family, per Plan Year 3 per family Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $5 100% Formulary Brand Name drug $20 100% Non-Formulary Brand Name drug $50 100% Mail Order Option (90-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $10 100% Formulary Brand Name drug $40 100% Non-Formulary Brand Name drug $ % GILSBARDM-# v37-Document.doc Page 8 of 8
CONRAD 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 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 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 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 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 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 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 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 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 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 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 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 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 informationHEALTH SAVINGS ACCOUNT (HSA)
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.
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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationFREEDOM BLUE PPO R CO 307 9/06. Freedom Blue PPO SM Summary of Benefits and Other Value Added Services
FREEDOM BLUE PPO R9943 2007 CO 307 9/06 Freedom Blue PPO SM Summary of Benefits and Other Value Added Services Introduction to Summary of Benefits for Freedom Blue January 1, 2007 - December 31, 2007 California
More informationCO-PAYMENT BOOK Las Vegas Blvd. South Suite 107 Las Vegas, NV
CO-PAYMENT BOOK 1901 Las Vegas Blvd. South Suite 107 Las Vegas, NV 89104 702-733-9938 www.culinaryhealthfund.org Revised January 2018 (Replaces Co-Payment Book dated June 2017) TABLE OF CONTENTS 4 5 6
More informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this
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 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 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 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 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 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 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 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 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 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 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 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 informationSchedule of Benefits Harvard Pilgrim Health Care, Inc.
Schedule of Benefits Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM-LAHEY SELECT HMO OOA MASSACHUSETTS 6-SPF, 01/13 MD0000002737 Please Note: In this plan, Member s have access to network benefits
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 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 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 information2018 CareOregon Advantage Plus (HMO-POS SNP) Summary of Benefits
2018 CareOregon Advantage Plus (HMO-POS SNP) Summary of Benefits For Oregon counties: Clackamas, Clatsop, Columbia, Jackson, Josephine, Multnomah, Tillamook, Washington and Yamhill H5859_1099_CO_1018 CMS
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 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 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 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 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 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 informationST. TAMMANY PARISH SCHOOL BOARD SCHEDULE OF BENEFITS
PLAN NAME ST. TAMMANY PARISH SCHOOL BOARD SCHEDULE OF BENEFITS St. Tammany Parish School Board Active Employee Plan PLAN'S ORIGINAL BENEFIT PLAN DATE PLAN'S AMENDED BENEFIT PLAN DATE GROUP NUMBER 78B03ERC
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 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 informationSchedule of Benefits - HMO 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 informationPROFESSIONAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, speech & occupational therapy Flu and pneumonia vaccinations Diagnostic services including
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 informationIrvine Unified School District ASO PPO /50
An Independent member of the Blue Shield Association Irvine Unified School District ASO PPO 500 90/50 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) THIS
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 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 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 - 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. 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 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 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 information