PLAN YEAR 2012 RETIREES HEALTH BENEFITS SUPPLEMENTAL BENEFITS PRESCRIPTION COVERAGE VISION COVERAGE DENTAL PLANS MENTAL HEALTH
|
|
- Archibald Gordon
- 5 years ago
- Views:
Transcription
1 HEALTH BENEFITS PERSONNEL EMPLOYEE BENEFITS ANTHEM BLUE CROSS HDPPO KAISER HMO THE HARTFORD GROUP MEDICARE RETIREE PLAN KAISER SENIOR ADVANTAGE - HIGH KAISER SENIOR ADVANTAGE - LOW SUPPLEMENTAL BENEFITS PRESCRIPTION COVERAGE VISION COVERAGE DENTAL PLANS MENTAL HEALTH PLAN YEAR 2012 MEDICAL PRESCRIPTIONS VISION DENTAL MENTAL HEALTH
2 $ $ Retiree Only Retiree + Spouse or $ $1, MetLife Dental DHMO $ $ Delta Dental DPPO or $ $ MetLife Dental DHMO PLAN 5 $1, $2, $2, $3, * MetLife Dental DHMO $ $ Delta Dental DPPO or $ $ MetLife Dental DHMO KAISER SENIOR ADVANTAGE - LOW Kaiser RX Kaiser Mental Health Kaiser Vision or * Not all Retiree Rate categories are included in this comparison sheet. Please contact Fresno County Employee Benefits at (559) if your situation is not identified. Delta Dental DPPO KAISER SENIOR ADVANTAGE - HIGH Kaiser RX Kaiser Mental Health Kaiser Vision HARTFORD / BENISTAR Express Scripts RX Avante Mental Health MES Vision Dental Plans PLAN 4 PLAN 3 $1, $2, $2, $3, * MEDICARE (AGE 65 AND OVER) Medical Prescription Vision Mental Health $ $ $1, $1, $1, Delta Dental DPPO $ $1, $1, $1, $1, MetLife Dental DHMO Retiree Only Retiree + Child(ren) Retiree + Spouse Retiree + Spouse and Child(ren) Medicare & Non Medicare or KAISER HMO Kaiser RX Kaiser Mental Health Kaiser Vision ANTHEM BLUE CROSS HDPPO Anthem Blue Cross RX Anthem Blue Cross Mental Health MES Vision Delta Dental DPPO PLAN 2 PLAN 1 MONTHLY PREMIUMS Dental Plans NON-MEDICARE (UNDER AGE 65) Medical Prescription Vision Mental Health This information summarizes certain key features of the health/dental plans. It is provided for your convenience in comparing plans only. In all cases, official documents legally govern the plans operations and benefits. Retirees must meet the eligibility requirements of the selected plan regarding service area limitations. All benefits are covered as stated only so long as plan requirements for prior authorization, primary care physician referral and/or bona fide emergency or medical necessity are met. All benefits with a notation, limit days indicate the maximum covered per calendar or contract year. Please contact Employee Benefits at (559) for eligibility and premium payment information. Those enrolling into a Medicare Plan must be eligible for Medicare Parts A + B to qualify for coordination of Benefits with the health plan. COUNTY OF FRESNO HEALTH CARE BENEFITS COMPARISON -
3 PLAN 1 HDPPO In Network PROVIDERS Out of Network PHYSICIAN SELECTION SKILLED NURSING 20% 40% (Service areas are defined Covered out-of-state services (Benefits FACILITY in each plan s benefit Freestanding SNF/ provided through the BlueCard Program) summary) Hospital SNF Unit Benefits provided through the BlueCard Program, for out-of-state emergency and OTHER BENEFITS non-emergency care, are provided at the preferred level of the local Blue Plan allowable Home Health Care/ Hospice Care/Inpatient amount when you use a Blue Cross/Blue Respite Care Shield provider. PHYSICIAN Office Visits/Hospital Care/Home Visits In Network Out of Network Limited to 100 days per calendar year. 40% after deductible. Limited to 100 days per calendar year. DURABLE MEDICAL EQUIPMENT 40% after deductible. Prosthetic Medical Devices Not limited to maximum. PREVENTIVE Preventive care (not subject to the calendar year deductible). Routine Physicals Pediatric and Adult/ 40% after deductible. Laboratory/ Immunizations/ Annual Breast and Pelvic CHIROPRACTIC, Limited to 24 visits per calendar year. PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY REHABILITATIVE Outpatient Services HOSPITAL ALLERGY TESTING AND TREATMENT HEARING TEST/ HEARING AID * 1 aid per ear every 36 months. EMERGENCY (When medically necessary) Ambulance EMERGENCY ROOM Accident or Illness INPATIENT Semiprivate Room, ICU Bariatric Surgery Area Hospitals including Saint Agnes, Community Medical Center of Fresno, Clovis Community Hospital, Children s Hospital Central California. * Not all hospitals are listed. Please visit the Anthem Blue Cross website for a complete listing at 20% INITIAL EVALUATION SPEECH AND HEARING DISORDERS 20% HEALTH EDUCATION 20% 20% DIABETES CARE 20% OUTPATIENT Surgery/X-RAY/ Lab Tests 40% after deductible. ACUPUNCTURE Not covered. 40% after deductible. 2 40% after deductible. 40% after deductible. Self-management training and education (if billed by your provider, you will also be responsible for the office visit co-payment). Equipment, devices and supplies. Limited to 12 visits per calendar year. Out of Network $30 maximum per visit. PROVIDERS Calendar-year Deductible: Individual $1,500/Family $3,000
4 PLAN 1 CONTINUED HDPPO $3,000 $5,000 Out of Network $10,000 $15,000 ANNUAL OUT OF POCKET MAXIMUM Individual Family In Network PRESCRIPTION DRUGS Benefits provided by Anthem B.C. Administered in Hospital or Dr. Office/Outpatient (Subject to deductible.) Prescriptions/Dental RX VISION BENEFITS Co-payments Examinations Eyeglasses Lenses Eyeglass Frames Contact Lenses Elective Contact Lenses Medically Necessary Lenses Laser Eye Surgery Lens Customization/ Additional Benefits MENTAL HEALTH Inpatient Outpatient Benefits provided by Medical Eye Services. $5.00 per covered person annually. Every 12 Months. In Network: Complete eye exam 100%. Out of Network: Maximum payable of $40. Every 12 Months. In Network: Covers standard lenses at 100%. Progressive lenses and polycarbonate lens coverage up to $ Additional allowances applied to some lens upgrades. Out of Network: Payable based on reimbursement benefit schedule. Every 24 Months. In Network: Allowance $ % discount of the amount over $150 on higher priced frames at participating discount provider locations. Out of Network: Maximum reimbursement of $75. Every 12 Months in lieu of eyeglasses. In Network: $130 maximum. Out of Network: $130 maximum. Every 12 Months. In Network: Paid in full. Out of Network: $250 maximum. Must be pre-authorized by MES Vision. 15% discount through TLC Vision network: Members responsible for optional upgrades such as lens tints and coatings. Some discounts may apply. Benefits provided by Anthem B.C. Prior authorization required after twelfth visit. 3 PROVIDERS
5 PLAN 2 HMO Primary care and specialty physician services SKILLED NURSING must be obtained at Kaiser Permanente FACILITY medical offices by teams of physicians Freestanding SNF/ affiliated with the Plan. You are encouraged to Hospital SNF Unit choose a personal physician from the staff for OTHER BENEFITS you and your family members. Referral to Routine Home Care/ community specialists may be provided when Inpatient Respite Care Specialty care services are unavailable at Kaiser Permanente facilities. Home Health Care/Home Hospice Care PHYSICIAN Office Visits $15 per provider visit. DURABLE MEDICAL Hospital Care No charge for inpatient care. EQUIPMENT Prosthetic Medical Devices Home Visits PHYSICAL, PREVENTIVE OCCUPATIONAL Routine Physicals AND SPEECH THERAPY Pediatric and Adult REHABILITATIVE Laboratory/ Immunizations Outpatient Services Annual Breast and Pelvic ALLERGY TESTING AND TREATMENT HOSPITAL Services available at Kaiser Permanente facilities. HEARING TEST EMERGENCY Worldwide coverage: Emergency service HEARING AID (When medically received within the service area from providers necessary) not contracting with health plan are limited to INITIAL EVALUATION emergencies which might result in death, SPEECH AND HEARING serious disability or significant jeopardy to the DISORDERS member s condition. Emergency services are provided outside the service area for members HEALTH EDUCATION/ DIABETES CARE becoming ill or injured while outside the service area. AMBULANCE $50 per trip. CHIROPRACTIC CARE EMERGENCY ROOM $100 per visit, waived if admitted. Accident or Illness INPATIENT Semiprivate Room, ICU/ Bariatric Surgery (Preauthorization Required) ACUPUNCTURE No charge at participating hospitals. Referral by a Plan physician required for all non-emergency hospital services. Limit 100 days per benefit period. No charge if prescribed by a Plan physician. 3 visits per day. 100 visits per year. 20% co-insurance. External prosthetic and orthotic devices. Occupational and speech therapy. $3 per injection. $1,000 per aid every 36 months. Most classes relating to specific medical conditions are Classes relating to general health are provided at a reasonable rate. $10 co-pay, limit 30 visits per calendar year. Services must be rendered by an American Specialty Health Plan Provider. Not covered. ANNUAL CO-PAYMENT $1,500 for one member. $3,000 for the LIMIT Subscriber and all his or her dependents. CLAIM FORMS OUTPATIENT Surgery $15 per procedure. X-RAY/Lab Tests 4 PHYSICIAN SELECTION (Service areas are defined in each plan s benefit summary) May be required for out-of-area emergency service.
6 PLAN 2 CONTINUED HMO Required. VISION BENEFITS Co-payments Examinations Eyeglasses Lenses/ Eyeglass Frames/Contact Lenses (Medically Necessary/Elective) Lens Customization/ Additional Benefits MENTAL HEALTH /CHEMICAL DEPENDENCY Inpatient Outpatient PRESCRIPTION DRUGS Administered in Hospital or Dr. Office Outpatient Prescriptions $10 co-pay (Generic); $20 co-pay (Brand), per 30-day supply. Mail orders: 100-day supply for two co-pays. Dental RX Same as outpatient. $175 allowance toward the purchase of covered lenses, frames and/or cosmetic contact lenses, every 24 months. Members responsible for non-basic lens options (tinting, scratch coating, photo-chromic lenses, etc.). 25% discount on second pair if purchased within one year. Benefits provided by Kaiser Permanente. Referral by a Plan physician required for all non-emergency admissions. $15 for an individual visit and $7 for a group visit. $5 for chemical dependency group visit. 5 COORDINATION OF BENEFITS
7 PLAN 3 GROUP MEDICARE RETIREE PLAN Disclaimer: The benefits described are for illustrative purposes only and are not binding. PHYSICIAN Office Visit Specialist Urgent Care The Hartford Product does not contract with providers. A member may receive health care services from any licensed provider as long as that provider participates in Original Medicare and is willing to accept the terms and conditions of the Hartford Medicare Supplement plan. OUTPATIENT Surgery $0 co-pay for each Outpatient Hospital Facility or Ambulatory Surgical Center visit for surgery. X-RAY/Lab Tests $0 co-pay for each Medicare-covered x-ray visit. $0 co-pay for Medicare-covered clinical/diagnostic lab test. $0 co-pay for each Medicare-covered visit. SKILLED NURSING FACILITY Freestanding SNF/ Hospital SNF Unit OTHER BENEFITS Home Health Care PREVENTIVE Routine Physicals Adult Laboratory Immunizations $0 co-pay (Influenza, Pneumonia and Hepatitis B). Annual Breast and Pelvic Pelvic & Pap Mammogram Home Hospice Care For Medicare-covered SNF stays: $0 co-pay per admission. $0 co-pay for Medicare covered home health visits. DURABLE MEDICAL 0% co-insurance on all Medicare-covered DME EQUIPMENT and related supplies. Prosthetic Medical Devices 0% co-insurance on all Medicare covered Prosthetic and related supplies. For Medicare-covered hospital stays: $0 co-pay PHYSICAL AND OCCUPATIONAL per admission. THERAPY, CARDIAC EMERGENCY This coverage is worldwide and is limited to AND PULMONARY (When medically what is allowed under the Medicare fee REHABILITATION AND necessary) schedule for the services performed/received SPEECH/LANGUAGE in the United States. Coverage is also available THERAPY for Emergency or urgent care services while ALLERGY TESTING traveling outside the United States during a AND TREATMENT temporary absence of less than 6 months. Please see EOC for full listing of coverage. HEARING TEST Ambulance $0 co-pay for Medicare-covered ambulance HEARING AID services. INITIAL EVALUATION EMERGENCY ROOM $0 co-pay for each Medicare-covered SPEECH & HEARING Accident or Illness emergency room visit. Emergency co-pay is DISORDERS waived if the member is admitted to the hospital within 72 hours for the same CHIROPRACTIC CARE condition. ACUPUNCTURE INPATIENT For Medicare-covered hospital stays: $0 co-pay ANNUAL CO-PAYMENT Semiprivate Room, ICU per admission. LIMIT HOSPITAL 6 $0 co-pay per visit for Medicare-covered outpatient rehabilitation services. Not covered. Not covered. $0 co-pay for each Medicare-covered visit. Not covered. Not applicable. CLAIM FORMS Not applicable. COORDINATION OF BENEFITS Medicare is primary payer. The Hartford is secondary. PHYSICIAN SELECTION (Service areas are defined in each plan s benefit summary) $0 Deductible
8 PLAN 3 CONTINUED GROUP MEDICARE RETIREE PLAN Benefits provided by the MES. $5 per visit. PRESCRIPTION DRUGS Preferred Generic Retail Generic Retail Preferred Brand and Specialty Retail Non-preferred Brand Retail Benefits provided by Express Scripts. $10 co-pay. $20 co-pay. MENTAL HEALTH Inpatient Benefits provided by the Hartford and Avante. For Medicare-covered Hospital Stays: $0 co-pay per admission. $0 co-pay for each Medicare-covered individual or group therapy visit. Additional services provided by Avante. Outpatient Disclaimer: The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This brochure/presentation explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. $175 allowance toward the purchase of covered lenses, frames and/or cosmetic contact lenses, every 24 months. Benefits provided by Medical Eye Services. Tinting, scratch coating, photo chromic lenses etc. Members responsible for non-basic lens options. 25% discount on second pair if purchased within one year. $30 co-pay. 7 VISION BENEFITS Co-payments Examinations Eyeglasses Lenses/ Eyeglass Frames/Contact Lenses (Medically Necessary/Elective) Lens Customization/ Additional Benefits
9 PLAN 4 SENIOR ADVANTAGE - HIGH PHYSICIAN SELECTION (Service areas are defined in each plan s benefit summary) PHYSICIAN Office Visits Hospital Care Home Visits OTHER BENEFITS Part time, intermittent care provided at no Routine Home Care and charge. Inpatient Respite Care/Home Health Care/Home Hospice Care Subscriber must have Medicare Parts A and B + D and live within the Kaiser Service Area. Physician's services are provided at Kaiser Permanente Medical Offices by teams of physicians affiliated with the Plan. You may choose a personal physician from the staff for you and your family members. DURABLE MEDICAL 20% co-insurance. EQUIPMENT Prosthetic Medical Devices 20% co-insurance. No charge when authorized by Plan physician. PHYSICAL, OCCUPATIONAL Inpatient provided at no charge. AND SPEECH THERAPY REHABILITATIVE Outpatient Services PREVENTIVE Routine Physicals Pediatric and Adult Laboratory Immunizations/ Annual Breast and Pelvic HOSPITAL Hospital services are provided at Kaiser Foundation Hospitals or at other hospitals contracting with the Plan. EMERGENCY Emergency services are provided at $50 per (When medically visit; waived if admitted. Must be medically necessary) necessary and authorized by Plan physician. Worldwide coverage for unforeseen illness or injury. Ambulance Provided at $100 co-pay when medically necessary or authorized by Plan Physician. EMERGENCY ROOM Accident or Illness $50 per visit, waived if admitted. INPATIENT Semiprivate Room, ICU ALLERGY TESTING AND TREATMENT $3 per injection. HEARING TEST HEARING AID $1,000 allowance per device, one device per ear, two devices every 36 months. HEALTH EDUCATION/ DIABETES CARE A variety of health education classes are available. CHIROPRACTIC CARE $10 co-pay, limit 30 visits per calendar year. Services must be rendered by an American Specialty Health Plan provider. ANNUAL CO-PAYMENT $1,500 for one member. LIMIT $3,000 for the Subscriber and all his or her dependents. OUTPATIENT Surgery $50 per procedure. X-RAY/Lab Tests SKILLED NURSING FACILITY Freestanding SNF/ Hospital SNF Unit Up to 100 days per benefit period. Each benefit period begins on the first day of acute stay or SNF stay and ends on the 61st day after discharge. A new benefit period then begins. Covered in Medicare-certified facility only by referral from Plan Physician. 8 CLAIM FORMS May be required for out-of-area emergency service. COORDINATION OF BENEFITS Not applicable.
10 PLAN 4 CONTINUED SENIOR ADVANTAGE - HIGH MENTAL HEALTH Inpatient Outpatient $175 allowance toward the purchase of covered lenses, frames and/or cosmetic contact lenses, every 24 months. Members responsible for non-basic lens options (tinting, scratch coating, photo-chromic lenses, etc.). 25% discount on second pair if purchased within one year. Referral by a Plan physician required for all non-emergency hospital admissions. $15 per visit; unlimited visits. No limit for parity diagnosis (severe mental illness). 9 VISION BENEFITS Co-payments Examinations Eyeglasses Lenses/ Eyeglass frames/contact Lenses (Medically Necessary/Elective) Lens Customization/ Additional Benefits PRESCRIPTION DRUGS Administered in Hospital or Dr. Office Outpatient Prescriptions Generic: $5 for up to 100-day supply. Brand: $20 for up to 100-day supply.
11 PLAN 5 SENIOR ADVANTAGE - LOW PHYSICIAN Office Visits Hospital Care Home Visits OTHER BENEFITS Part time, intermittent care provided at no Routine Home Care and charge. Inpatient Respite Care/Home Health Care/Home Hospice Care Subscriber must have Medicare Parts A and B + D and live within the Kaiser Service Area. Physician's services are provided at Kaiser Permanente Medical Offices by teams of physicians affiliated with the Plan. You may choose a personal physician from the staff for you and your family members. No charge when authorized by Plan physician. PREVENTIVE Routine Physicals Pediatric and Adult Laboratory Immunizations/ Annual Breast and Pelvic HOSPITAL Hospital services are provided at Kaiser Foundation Hospitals or at other hospitals contracting with the Plan. EMERGENCY Emergency services are provided at $50 per (When medically visit; waived if admitted. Must be medically necessary) necessary and authorized by Plan physician. Worldwide coverage for unforeseen illness or injury. Ambulance $100 co-pay when medically necessary or authorized by Plan Physician. EMERGENCY ROOM Accident or Illness $50 per visit, waived if admitted. INPATIENT Semiprivate Room, ICU PHYSICAL, OCCUPATIONAL Inpatient provided at no charge. AND SPEECH THERAPY REHABILITATIVE Outpatient Services ALLERGY TESTING AND TREATMENT $3 per injection. HEARING TEST HEARING AID $1,000 allowance per device, one device per ear, two devices every 36 months. HEALTH EDUCATION/ DIABETES CARE A variety of health education classes are available. CHIROPRACTIC CARE $10 co-pay, limit 30 visits per calendar year. Services must be rendered by an American Specialty Health Plan provider. ANNUAL CO-PAYMENT $1,500 for one member. LIMIT $3,000 for the Subscriber and all his or her dependents. OUTPATIENT Surgery $50 per procedure. X-RAY/Lab Tests SKILLED NURSING FACILITY Freestanding SNF/ Hospital SNF Unit DURABLE MEDICAL 20% co-insurance. EQUIPMENT Prosthetic Medical Devices 20% co-insurance. CLAIM FORMS May be required for out-of-area emergency service. COORDINATION OF BENEFITS Not applicable. Up to 100 days per benefit period. Each benefit period begins on the first day of acute stay or SNF stay and ends on the 61st day after discharge. A new benefit period then begins. Covered in Medicare-certified facility only by referral from Plan Physician. 10 PHYSICIAN SELECTION (Service areas are defined in each plan s benefit summary)
12 PLAN 5 CONTINUED SENIOR ADVANTAGE - LOW VISION BENEFITS Co-payments Examinations Eyeglasses Lenses/ Eyeglass frames/contact Lenses (Medically Necessary/Elective) Lens Customization/ Additional Benefits MENTAL HEALTH Inpatient Outpatient $175 allowance toward the purchase of covered lenses, frames and/or cosmetic contact lenses, every 24 months. Members responsible for non-basic lens options (tinting, scratch coating, photo-chromic lenses, etc.). 25% discount on second pair if purchased within one year. Referral by a Plan physician required for all non-emergency hospital admissions. $15 per visit; unlimited visits. No limit for parity diagnosis. 11 PRESCRIPTION DRUGS Administered in Hospital or Dr. Office Outpatient Generic: $10 for up to 30-day supply. Brand: $25 for up to 30-day supply. Prescriptions Generic: $20 for up to 100-day mail order supply. Brand: $50 for up to 100-day mail order supply.
13 $2,500 per person per year. (Maximum Waived for Diagnostic, Orthodontia & Preventive Services) Covered the same as routine services. Participating dentists will submit claim forms for you. The plan will coordinate with other coverages if the person is qualified in more than one plan. No service limitations in California. MAXIMUM BENEFITS Predetermination of Benefits EMERGENCY CLAIM FORMS COORDINATION OF BENEFITS SERVICE AREA 0% *(Deductible Waived) 0% (Deductible Waived) *Extra visit for pregnancy. 10% 10% DHMO Plan SUPPLEMENTAL No charge (except for resin/composite fillings on posterior teeth; the co-pays for these procedures range from $85-$140). The no charge is for amalgam for all teeth and resin/composite for anterior teeth. No service limitations in California. The plan will coordinate with other coverages if the person is qualified in more than one plan for specialty claims only. No claim forms are necessary except for out-of the-area emergencies. Palliative treatment of pain only. No annual maximum. No deductible. Members must select a dentist from the list of Plan approved dentists. Members receive benefits from one of the participating dentists in the network. The plan covers most preventive diagnostic, restorative and other basic procedures at NO CHARGE. Major procedures may require fixed co-pays. Preventive Services/Cleanings & Fluoride Treatment BENEFIT PROVISIONS BASIC/PREVENTIVE Diagnostic Services Examinations, X-rays, Check-ups Basic and Major Services: $50 per person, $150 per family per calendar year. No deductible for Preventive/Diagnostic services from a PPO dentist, and Orthodontic services. DEDUCTIBLE Non-preferred Provider Dentist All covered persons may select a dentist without restriction. If a participating dentist is selected, the member may have a reduction in out-of-pocket costs. DENTIST SELECTION Preferred Provider Dentist Plan will pay a portion of the bill after deductible is met. The Plan s portion for covered basic and preventive services is 100% of the covered dental expense. All covered major services and some basic services are paid at 50% of the covered dental expense. Dental implants and composite fillings may be covered. DPPO Plan SUMMARY
14 DHMO Plan SUPPLEMENTAL CONTINUED Lost/stolen appliances; Cosmetic dentistry (except those noted within the schedule of benefits); Hospital expenses; Replacement of repairable dentures; Orthognatic surgery; Implants; Experimental/unnecessary procedures; Treatment to alter vertical dimension; TMJ treatment; Other exclusions/limitations as provided in policy. Adult member (age 20 and over) $1,400 co-pay per case. Child member (through age 19) $1,300 co-pay per case. Most services do not require a co-pay. Co-pay may be required for an upgrade from a base metal to a precious metal. No charge, except for teeth bleaching. Members receive benefits from one of the participating dentists in the network. The plan covers most preventive diagnostic, restorative and other basic procedures at NO CHARGE. More than two cleanings per calendar year; Lost/stolen appliances; Cosmetic dentistry; Charges in excess of customary for Nonparticipating dentists; Hospital expenses; Prescription drugs; Replacement of prosthetics within 5 years of placement; Unnecessary/Experimental procedures; Treatment to alter vertical dimension; TMJ treatment; Other exclusions/limitations as provided in policy. 50% EXCLUSIONS/LIMITATIONS 50% MAJOR - Oral Surgery Impactions/Root Canals/ Apicoectomy/Periodontal Surgery/Crowns/Bridges/ Dentures/Other Prosthetics/ Simple Extractions/Implants (DPPO Only) 50% Adult member (age 20 and over) $1,880 co-pay per case. Child member (through age 19) $1,660 co-pay per case. One case per lifetime. Maximum of 24 months of active orthodontic treatment. 50% OTHER - Endodontics (minor)/treatment of Gums (minor)/teeth Bleaching (DHMO Only) 10% Non-preferred Provider Dentist DPPO Plan OTHER BENEFITS - Orthodontia* (Teeth Straightening - Adults and Children) 10% Preferred Provider Dentist Restorative Services/Fillings, Pulp Capping
15 ADDITIONAL RESOURCES FOR w w w. c o. f re s n o. c a. u s / o p e n e n ro l l m e n t MEDICAL Anthem Blue Cross HDPPO ($1,500) / Phone: (866) Kaiser HMO Pre-65 / Phone: (800) The Hartford / Benistar / Phone: (800) Kaiser Senior Advantage (High and Low) / Phone: (800) /7 Nurseline for HDPPO / Phone: (866) DENTAL Delta Dental DPPO Group Number: 5879 / Phone: (800) MetLife Dental DHMO / Phone: (800) VISION MEDICAL EYE Group Number: / Phone: (800) MENTAL HEALTH AVANTE Phone: (559) PERSONNEL EMPLOYEE BENEFITS OPEN ENROLLMENT OFFICE 2220 Tulare Street, 14th Floor Fresno, California Phone: (559) Designed & Printed by: Graphic Communication Services Phone: (559)
Gold Access+ HMO 500/35 OffEx
An Independent Member of the Blue Shield Association Gold Access+ HMO 500/35 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective
More informationPlatinum Trio ACO HMO 0/20 OffEx
Platinum Trio ACO HMO 0/20 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO
More informationBlue Shield Gold 80 HMO 0/30 + Child Dental INF
Blue Shield Gold 80 HMO 0/30 + Child Dental INF Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX
More informationBlue Shield Gold 80 HMO
Blue Shield Gold 80 HMO Uniform Health Plan Benefits and Coverage Matrix Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND
More informationBlue Shield $0 Cost-Share HMO AI-AN
Blue Shield $0 Cost-Share HMO AI-AN This plan is only available to eligible Native Americans 1 Uniform Health Plan Benefits and Coverage Matrix Blue Shield of California Effective January 1, 2017 THIS
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 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 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 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 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 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 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 informationThis plan is pending regulatory approval.
Bronze Full PPO 3000 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective October 1, 2015 THIS MATRIX IS INTENDED TO BE USED
More informationFreedom Blue PPO SM Summary of Benefits
Freedom Blue PPO SM Summary of Benefits R9943-206-CO-308 10/05 Introduction to the Summary of Benefits for Freedom Blue PPO Plan January 1, 2006 - December 31, 2006 California YOU HAVE CHOICES IN YOUR
More informationMyHPN Solutions HMO Gold 7
MyHPN Solutions HMO Gold 7 HIOS ID: 95865NV0030074 Attachment A Benefit Schedule Calendar Year Deductible (CYD): $3,000 of EME per Member and $6,000 of EME per family. The Calendar Year Out of Pocket Maximum
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 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 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 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. New York: Bronx, Kings, New York, Queens and Richmond Counties
Summary of Benefits New York: Bronx, Kings, New York, Queens and Richmond Counties January 1, 2006 - December 31, 2006 You ve earned the right to live life on your own terms. And that includes the right
More informationSummary of Benefits Advantra Freedom PEBTF
Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation
More informationSummary of Benefits Platinum 90 HMO Trio
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum 90 HMO Trio Individual and Family Plan HMO Benefit Plan This Summary of Benefits shows the
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 informationSummary of Benefits Silver 70 HMO Trio
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Silver 70 HMO Trio Individual and Family Plan HMO Benefit Plan This Summary of Benefits shows the amount
More informationFirst Look: Plan Benefit Filings
July 30, 2014 First Look: Plan Filings Maryland and Washington, D.C. 1 Disclaimers MedStar does not currently have a contract with CMS for the State of MD nor any special needs plans in Washington, D.C.
More informationAnthem Blue Cross Your Plan: Modified Classic HMO 15/30/250 Admit/125 OP Your Network: California Care HMO
Anthem Blue Cross Your Plan: Modified Classic HMO 15/30/250 Admit/125 OP Your : California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.
More informationVivity offered by Anthem Blue Cross Your Plan: Custom Classic HMO 25/45/500 Admit /250 OP Your Network: Vivity
Vivity offered by Anthem Blue Cross Your Plan: Custom Classic HMO 25/45/500 Admit /250 OP Your : Vivity This summary of benefits is a brief outline of coverage, designed to help you with the selection
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 informationHOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private ro
Blue Shield Gold 80 HMO 0/35 Network 1 Mirror w/ Child Dental Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2016
More informationAnthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your Network: California Care HMO
Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your : California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary
More informationAnthem Blue Cross Your Plan: Modified Classic HMO 20/40/250 Admit /125 OP Your Network: California Care HMO
Anthem Blue Cross Your Plan: Modified Classic HMO 20/40/250 Admit /125 OP Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection
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 informationVivity offered by Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your Network: Vivity
Vivity offered by Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your : Vivity This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary
More informationAnthem Blue Cross Your Plan: Custom Premier HMO 25/100 admit 3 day max/100 OP Your Network: California Care HMO
Anthem Blue Cross Your Plan: Custom Premier HMO 25/100 admit 3 day max/100 OP Your : California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection
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 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 informationHEALTH PLANS FOR PARTICIPANTS
Kern County 2018 Retiree HEALTH PLANS FOR PARTICIPANTS OVER AGE 65 (Must have BOTH Medicare Parts A & B) For current participating physician information, please contact each plan directly. This summary
More informationGOLD 80 HMO NETWORK 1 MIRROR
GOLD 80 HMO NETWORK 1 MIRROR Summary of Benefits Group An independent member of the Blue Shield Association (Intentionally left blank) Gold 80 HMO Network 1 Mirror Summary of Benefits The Summary of Benefits
More informationUNIVERSITY OF CALIFORNIA UNITEDHEALTHCARE SELECT EPO - NON-MEDICARE
Select EPO Non-Medicare Plan UNITEDHEALTHCARE SELECT EPO - NON-MEDICARE ELIGIBILITY DEDUCTIBLES 1 Individual Family OUT-OF-POCKET LIMIT 2 Individual Family HOSPITAL SERVICES 3 surgery Surgeon/assistant
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 information1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS
1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS I HOSPITAL CARE This benefit is for the hospital s charge for the use of its facility only. Coverage for services rendered by doctors, labs,
More informationGold Local Access+ HMO 750/30 OffEx
Gold Local Access+ HMO 750/30 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2016 THIS MATRIX IS INTENDED
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 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 information2016 OPEN ENROLLMENT MEDICAL PLANS
2016 OPEN ENROLLMENT MEDICAL PLANS Table of Contents Section I. Enrollment Guidelines Page 3 Health Plan Comparison Chart Page 4 Health Plan Premiums and Employee Cost-Sharing Page 5 Section II. Blue Shield
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 informationBlueChoice HMO HSA/HRA Silver 2000 Integrated Deductible
BlueChoice HMO HSA/HRA Silver 2000 Integrated Deductible Summary of Benefits Services In-Network You Pay 1 FIRSTHELP 24/7 NURSE ADVICE LINE Free advice from a registered nurse. Visit www.carefirst.com/needcare
More informationAnthem Blue Cross Your Plan: Core PPO Your Network: National PPO (BlueCard PPO)
Anthem Blue Cross Your Plan: Core PPO Your Network: National PPO (BlueCard PPO) This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does
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 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 informationThe HMO provider network is available by clicking on this website address: Plan Provider Directory Search<b/>
GENERAL PROVISIONS Web Site Address Find a Plan Doctor or Facility Health Plan Telephone Number NCQA Accreditation Status http://www.bcbsil.com The HMO provider network is available by clicking on this
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 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 informationSUMMACARE BRONZE 4000Q-15 SCHEDULE OF BENEFITS
SUMMACARE BRONZE 4000Q-15 SCHEDULE OF BENEFITS Enrollee Services Per Member/Per Family Calendar Year Deductible (In-network and out-of-network deductibles are separate. Deductible applies to all covered
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 informationMedical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage
Program Name U of M Retiree Plan with Group MedicareBlue SM Rx Group Platinum Blue SM Plan C with Group MedicareBlue SM Rx Freedom Plan & Freedom Plan & Type of Policy Coordinates with Medicare and includes
More informationSchedule of Benefits-EPO
Schedule of Benefits-EPO [Plan Information] [Health Plan:] [Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan] [Primary Member:] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]
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 informationCongressional Regional Plan BlueChoice HMO Referral Gold 80 Non-Integrated Deductible
Congressional Regional Plan BlueChoice HMO Referral Gold 80 Non-Integrated Deductible Summary of Benefits Services In-Network You Pay 1 FIRSTHELP 24/7 NURSE ADVICE LINE Free advice from a registered nurse.
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 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 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 informationSummary Of Benefits. WASHINGTON Pierce and Snohomish
Summary Of Benefits WASHINGTON Pierce and Snohomish 2018 Molina Medicare Choice (HMO SNP) (800) 665-1029, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local time H5823_18_1099_0007_WAChoSB Accepted 9/26/2017
More informationAll but Part A Deductible. Medicare Part A Deductible. Nothing. Inpatient Hospital All but Part A Medicare Part A Nothing.
Summary of Signature 65 Benefits Signature 65 is a Medicare-complimentary benefit program that fills in the coverage gaps and cost sharing of the traditional Medicare program (Medicare Part A and ). In
More informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2015 December 31, 2015 Los Angeles County This publication is a supplement to the 2015 Evidence of Coverage and
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 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 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 informationSmartSaver. A Medicare Advantage Medical Savings Account Plan. Summary of Benefits and Other-Value Added Services. From Blue Cross of California
SmartSaver From Blue Cross of California A Medicare Advantage Medical Savings Account Plan Service Area C Summary of Benefits and Other-Value Added Services H5769 2007 CO 415 09/22/06 Introduction to the
More informationChoice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members
Choice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members DEDUCTIBLE (per calendar year) Annual in-network deductible must be paid first for the following services: Imaging, hospital
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 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 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 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 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 informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2011 December 31, 2011 Los Angeles County This publication is a supplement to the 2011 Positive (HMO SNP) Evidence
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 Health Net. seniority plus green. Benefits effective January 1, 2009 H0562 Medicare Advantage HMO
2009 Health Net Summary of benefits Los Angeles, Orange, Riverside and San Bernardino counties s effective January 1, 2009 H0562 Medicare Advantage HMO Material ID H0562-09-0041 CMS Approval 9/08 Section
More informationMedical Plans Benefit Guide
Medical Plans Benefit Guide Employers with 1-50 employees 1.1.01 Provider network built for value and quality... Wellness rewards...3 Medical Travel Support and Air or Surface Transportation... Support
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 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 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 Benefits for SmartValue Classic (PFFS)
Summary of Benefits for SmartValue Classic (PFFS) Available in Select Counties in Nevada A health plan with a Medicare contract. Rocky Mountain Hospital and Medical Service, Inc. has contracted with the
More informationMedicare Retirees - County Of Sonoma New Medical Plan Options Comparison Chart for 2008/2009 (With Consumer Driven Health Plan)
DEDUCTIBLE $1,000 individual $3,000 family $500 individual $1,500 family None None HRA AMOUNT $500 individual (does not apply towards Out of Pocket Maximum) $1,500 family (does not apply towards Out of
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 informationMEDICARE CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS.
ine 1-800-544-0088 www.care1st.com CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS MEDICARE 2009 COUNTIES: LOS ANGELES - ORANGE - SAN BERNARDINO - SAN DIEGO H5928_09_004_SNP_SB 10/2008 Section I Introduction
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 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 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 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 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 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 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 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 informationAnthem Blue Cross Effective: January 1, 2017 Your Plan: University of California High Option Supplement to Medicare
Anthem Blue Cross Effective: January 1, 2017 Your Plan: University of California High Option Supplement to Medicare Please Note: this medical plan is a complement to your existing Medicare plan. Medicare
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 informationspecial needs plan (hmo snp) MEDICARE advantage plan summary of benefits Serving Members in Douglas & Klamath Counties
special needs plan (hmo snp) 2017 MEDICARE advantage plan summary of benefits Serving Members in Douglas & Klamath Counties Table of Contents About the Summary of Benefits... 2 Who Can Join?... 2 Which
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 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 informationGetting the Most from Your COVA CARE PLAN
Getting the Most from Your COVA CARE PLAN July 1, 2014 through June 30, 2015 Commonwealth of Virginia Your COVA CARE PLAN TABLE OF CONTENTS What s In Your COVA Care Plan?.... 2 Let s Dive In - Medical
More information