Security Forces SCHEDULE OF BENEFITS Participating Provider Covered Person pays:
|
|
|
- Robert Hall
- 5 years ago
- Views:
Transcription
1 Benefit Local Office Visits/Physician Consultation (per visit/occurrence) Primary Care, Specialist and Walk in Clinics Security Forces Participating Provider Prescription Service rendered at a pharmacy Laboratory Diagnostic Ultra Sound Prescription Service rendered in a physician s office Laboratory Diagnostic Ultra Sound Service rendered at a facility CAT Scan PET Scan MRI Scan Medical Supplies Pre-Certification required $100 Co-payment Pre-Certification required
2 Immunization Preventive Care Security Forces Preventive Care Routine Immunization for dependent children Covered at 100% Please contact Colina for benefits Annual Health Check Mammogram one per calendar year (for insured females age 35 years and older) Pap Smear one per calendar year (for insured females age 21 years and older) Annual Prostate Exam one per calendar year (for insured males age 40 years and older) PSA Test one per calendar year (for insured males age 40 years and older) Annual Maximum - $ per individual In-office Surgery In-Office Surgical Expenses In-office Anesthesia Pre-certification required for procedures $ and above In-Office Anesthesia All payments are based upon Reasonable and Customary charges. Non pre-certification requires Covered Person to pay deductible 50% Co-insurance of Reasonable and Customary charges, subject to the respective benefit maximums. Pre-Certification is required for the following: - Hospitalizations - Out-Patient surgical procedures (whether provided at a hospital, ambulatory surgical Centre or a physician s office)
3 - Magnetic Resonance Imaging services - Durable Medical Equipment - Rehabilitation/ Skilled Nursing Facility Confinements - Home Health Services - Human Organ Transplants - In-Patient Treatment - Behavioral Health Disorders - Air Transportation (ambulance or commercial airfare) - Outside The Bahamas daily allowances - Return of deceased/repatriation Exclusions No benefits are payable for: 1. The evaluation of routine and other treatment of learning disabilities; 2. Pregnancies whose conception occurs prior to the Effective Date; 3. Industrial Accidents 4. Treatment for pre-existing ailments occurring within the first 12 months of the policy 5. Self inflicted injury, suicide or attempted suicide 6. Non-medical equipment 7. Maximum benefit limits 8. Expenses incurred after termination date 9. Treatment by a close relative who or an occupant living in the covered person s home. 10. Recreational or educational therapy 11. Radioactive contamination 12. Treatment or injury arising from war or war related activity, voluntary participation in assaults, civil commotions, conspiracies, riots, public disturbances, high risk sports (but not limited to, parachuting, skydiving, water skiing, diving, mountain climbing, bungee jumping, motor vehicle or powerboat racing, hand gliding, ballooning and reckless endangerment of any form 13. The following drugs, medicines or supplies, even if prescribed by a Physician: a. Vitamins, dietary supplements, appetite suppressants, hair regenerative or cosmetics, health and beauty aids, nicorette gum or smoking suppressants;
4 b. Experimental or Investigative drugs, medicines, or supplies; c. OTC drugs and medication; d. Contraceptive drugs or devices, prescription or otherwise, unless prescribed for other than contraceptive purposes to treat a medically diagnosed condition; e. Drugs prescribed for non-medical conditions, or drugs for conditions which are not covered under this Policy; 14. In addition to the above, the following out-patient drugs are not covered: (all of the below) a. Accutane (Isotretinoin); b. All forms of Retin (Retinoid Acid); c. AIDS specific drugs not yet approved for use and still in the experimental stage; d. Progesterone suppositories (except in complications of pregnancy); e. Fertility drugs; f. Immunosuppressants (unless under the control of a Physician); g. Monoxidil for topical use. 15. Infertility test, treatment and related procedures, including hormonal treatment, pregnancies and new born children born as a result of fertility treatment. 16. Weight loss, weight control programs including surgical intervention, unless medically necessary to treat Endogenous Morbid Obesity diagnosed by a Physician. 17. Personal or comfort items such as radio, television, barber or beauty services; 18. Charges by any provider of care or service who or which is not duly licensed or certified to render the treatment or services provided; or any service or supply not prescribed by a qualified Physician; 19. Maternity charges for dependent children and unenrolled spouses. 20. Any service or supply not provided in accordance with accepted medical or professional standards of practice; or which is Experimental or Investigative in nature, or is research oriented; 21. Any service or supply not specifically listed as a benefit under this Policy; 22. Weekend charges incurred for Hospital Confinements that start on Friday, Saturday or Sunday, unless:
5 a. the attending Physician certifies that such weekend admission is Medically Necessary; or b. such weekend Hospital Confinement is in connection with a surgery scheduled for the day that next follows the date of admission (Saturday, Sunday or Monday); 23. Any Charges for elective abortions; 24. Any expense, charge or fee that exceeds the Usual Customary and Reasonable amount.
PLAN 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
$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,
MERCY 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
FAQS FOR UNIVERSITY OF SOUTH FLORIDA BUSINESS TRAVELERS
FAQS FOR UNIVERSITY OF SOUTH FLORIDA BUSINESS TRAVELERS How long am I covered? A: The plan covers you for trips that are taken related to USF business travel during September 1, 2017 and August 31, 2018.
HEALTH 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 -
ESSENTIAL 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
Blue 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.
Member 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.
TRADITIONAL 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
HEALTH 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
MEDICAL PLAN EXCLUSIONS. For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:
MEDICAL PLAN EXCLUSIONS For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered: (1) Abortion. Services, supplies, care or treatment in connection with an
Optional 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
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
CA 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
Health 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:
UNIVERSITY 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
Direct Care Deductible 2000 Hybrid Benefit Summary Benefits effective January 1, 2018 and beyond
Direct Care Deductible 2000 Hybrid Benefit Summary Benefits effective January 1, 2018 and beyond The Fallon difference Direct Care is a Limited Provider Network. With Direct Care Deductible 2000 Hybrid,
PLAN 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
Aetna 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
Optional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
Select Care Deductible 1200 Hybrid Benefit Summary Benefits effective January 1, 2018 and beyond
Select Care Deductible 1200 Hybrid Benefit Summary Benefits effective January 1, 2018 and beyond The Fallon difference With Select Care Deductible 1200 Hybrid, you get everything you need to live a healthy
CALIFORNIA 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
BENEFIT 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
CLASSIC 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
AETNA PPO PLAN COVERED DEPENDENTS UNDER 65
AETNA PPO PLAN COVERED DEPENDENTS UNDER 65 Plan Deductible (per calendar year; applies to all covered services; excludes deductible carryover.) $300 Individual $600 Family $600 Individual $1200 Family
Updated: 10/01/12 Page : 1
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family
Aetna Fixed Indemnity Plan Helps pay for the costs of everyday medical expenses
Aetna Fixed Indemnity Plan Helps pay for the costs of everyday medical expenses Extra benefits when you need them Do you have security in knowing you have help handling your medical expenses? You can with
PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $250 Individual None Family $750 Family Unless otherwise indicated, the deductible must be met prior to benefits being
1199SEIU 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,
PREFERRED 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
High 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
Regence 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:
Stanislaus 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
HEALTH 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.
RSNA 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:
FCPS 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
Your 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
Kaiser 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
WILLIS 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
Blue 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
OVERVIEW OF YOUR BENEFITS
OVERVIEW OF YOUR BENEFITS IMPORTANT PHONE NUMBERS Member Services Department (646) 473-9200 For answers to questions about your benefits or to be referred to another Benefit Fund department. Program for
CITY OF SLIDELL S2630 NON-GRANDFATHERED BENEFIT SHEET
CITY OF SLIDELL S2630 BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 No later than 365 days after the Filing Limit date expenses are incurred
NY 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)
Kaiser 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.
Central 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
Welcome Plan. Basic health insurance for temporary, new and returning Canadian residents
Welcome Plan Basic health insurance for temporary, new and returning Canadian residents Help your newest plan members feel at home Recognizing the skills and fresh perspectives that a diverse organization
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
2018 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
Central 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
SISC Blue Shield of California 90% Plan C $10 Copayment Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix)
SISC Blue Shield of California 90% Plan C $10 Copayment Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
SUMMARY 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,
BCBSM 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
Amherst 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
SUMMARY 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
Single/Family $2,500/$5,000 $5,000/$10,000. Single/Family $6,000/$12,000 $10,000/None. Single/Family $5,000/$10,000 $6,250/$12,500
Plan Information Provider networks: Members have direct access to their choice of providers. Member cost-sharing is lowest for In-Network providers. If a member chooses an Out-of-Network provider, the
UNIVERSITY 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
Your 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,
PLAN DESIGN & BENEFITS
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) Poway Unified School District None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include
Summary of Benefits. January 1, 2018 December 31, Providence Medicare Dual Plus (HMO SNP)
Summary of Benefits January 1, 2018 December 31, 2018 Providence Medicare Dual Plus (HMO SNP) This plan is available in Clackamas, Multnomah and Washington counties in Oregon for members who are eligible
What Your Plan Covers and How Benefits are Paid SUMMARY BOOKLET. Prepared Exclusively for Six Continents Hotels, Inc. Elect Choice
SUMMARY BOOKLET What Your Plan Covers and How Benefits are Paid Prepared Exclusively for Six Continents Hotels, Inc. Elect Choice Table of Contents Preface...1 Important Information Regarding Availability
UnitedHealthcare 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
Kaiser 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
Regence EmployeeChoice Plan Highlights Platinum 250, Platinum 500, Gold 500, Gold 1000, Gold 1500, Silver 2500, Bronze Essential /1/2016
Plan Information Provider networks: Members have direct access to their choice of providers. Member cost-sharing is lowest for In-Network providers. If a member chooses an Out-of-Network provider, the
Schedule of Benefits - Point of Service MOSINEE SCHOOL DISTRICT Benefit Year: January 1st Through December 31st Effective Date: 07/01/2016
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
$2,000 Individual. Deductible (per calendar year)
PLAN FEATURES Deductible (per calendar year) FAMILY PHYSICIANS GROUP $2,000 Individual $4,000 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost
Steward Community Care Choice 2000 (HSA)
Steward Community Care Choice 2000 (HSA) Benefit Summary Benefits effective April 1, 2013 and beyond The FCHP difference FCHP Steward Community Care is a limited network HMO plan designed in partnership
SISC Blue Shield of California 100% Plan A - $0 Copayment (Uniform Health Plan Benefits and Coverage Matrix)
SISC Blue Shield of California 100% Plan A - $0 Copayment (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS
HEALTH PLAN BENEFITS AND COVERAGE MATRIX
HEALTH PLAN BENEFITS AND COVERAGE MATRIX THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR
Schedule 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,
Covered Services List
CAREPLUS Covered Services List For CeltiCare Health with MassHealth CarePlus Coverage This is a list of all covered services and benefits for MassHealth CarePlus enrolled in CeltiCare Health. The list
Cigna 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
UNM Medical Plan. summary of benefits. Effective: July 1, 2012
UNM Medical Plan summary of benefits Effective: July 1, 2012 Offered by The Regents of the University of New Mexico Administered by Lovelace Insurance Company administered by ANNUAL PLAN YEAR DEDUCTIBLE
Schedule 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
PRUPARENT/PRUHOSPITAL INCOME ROOM & BOARD/SURGICAL BENEFIT MEDICAL REPORT FORM (To be completed by Medical Attendant)
Reg. 199002477Z PRUPARENT/PRUHOSPITAL INCOME ROOM & BOARD/SURGICAL BENEFIT MEDICAL REPORT FORM (To be completed by Medical Attendant) Policy Number Part 1 Medical Information 1. Name of Patient 2. NRIC
WHAT DOES MEDICALLY NECESSARY MEAN?
WHAT DOES MEDICALLY NECESSARY MEAN? Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary as defined below. Medically Necessary means appropriate and necessary
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/0% These services are covered as indicated when authorized through your Primary Care
UnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Alliance Offered by UnitedHealthcare of California HMO Deductible Schedule of Benefits HRA-QUALIFIED DEDUCTIBLE HEALTH PLAN 35-50/20%/2000DED
Summary 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
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO 20 (20/0%) EFFECTIVE JULY 1, 2017 These services are covered as indicated when authorized through your Primary Care Physician
SCHEDULE A SMITHFIELD FOODS HEALTHCARE PROGRAM SUMMARY PLAN DESCRIPTION EXCLUSIONS
SCHEDULE A SMITHFIELD FOODS HEALTHCARE PROGRAM SUMMARY PLAN DESCRIPTION EXCLUSIONS 1. General Exclusions. In addition to the Plan's other restrictions, no Plan benefit is payable for any of the following
PacifiCare SignatureValue Advantage Offered by PacifiCare of California
CALIFORNIA SMALL GROUP PacifiCare SignatureValue Advantage Offered by PacifiCare of California 30-40/500d HMO Schedule of Benefits Effective March 1, 2010 These services are covered as indicated when authorized
Anthem 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
Schedule 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
Annual copay maximum: Individual $500; Family $1,500 The following copay does not apply to the annual copay maximum: for infertility services
Custom Premier HMO 30/100 (HMO 30 w/o CHIRO) Effective 07.01.2017 This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits in your plan,
HOME 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
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
2016 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
UnitedHealthcare SignatureValue TM UnitedHealthcare SignatureValue Advantage Offered by UnitedHealthcare of California
CALIFORNIA SMALL GROUP UnitedHealthcare SignatureValue TM UnitedHealthcare SignatureValue Advantage Offered by UnitedHealthcare of California 20-40/300d HMO Schedule of Benefits These services are covered
Anthem 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
SUMMARY OF BENEFITS. Features that Add Value. It's Your Health. You Can Depend on CIGNA HealthCare. It's Your Choice
SUMMARY OF BENEFITS Your CIGNA HealthCare Open Access Plus plan Features that Add Value Your plan offers the convenience of referral-free access to doctors, and the option to select a personal Primary
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California HMO Schedule of Benefits 20/250A These services are covered as indicated when authorized through your
SUMMARY OF BENEFITS Your CIGNA HealthCare Indemnity plan
SUMMARY OF BENEFITS Your CIGNA HealthCare Indemnity plan Features that Add Value The CIGNA HealthCare 24-Hour Health Information Line SM connects you to registered nurses and a library of hundreds of recorded
UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California
CALIFORNIA SCHOOLS VEBA UnitedHealthcare SignatureValue TM Offered by UnitedHealthcare of California Performance HMO Schedule of Benefits (Package A, Network 1) 10/0% These services are covered as indicated
SCHEDULE 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
SUMMARY OF BENEFITS. It's Your Health. Features that Add Value. You Can Depend on CIGNA HealthCare. Quality Service Is Part of Quality Care
SUMMARY OF BENEFITS Your CIGNA HealthCare HMO plan Features that Add Value The CIGNA HealthCare 24-Hour Health Information Line SM connects you to registered nurses and a library of hundreds of recorded
Protection Series Recovery Care Insurance Plans
Underwritten by Continental Life Insurance Company of Brentwood, Tennessee An Aetna Company Protection Series Recovery Care Insurance Plans SM Security solutions. For peace of mind protection. North Carolina
Chapter 12 Benefits and Covered Services
12 Benefits and Covered Services Health Choice Generations covers the same benefits covered under Original Medicare. Sometimes Medicare adds coverage for a new service during the year. Health Choice Generations
THIS INFORMATION IS NOT LEGAL ADVICE
Medicaid Medicaid is a federal/state program that gives certain groups of people a card that can be used to get free medical care, nursing home care, and prescription drugs at reduced prices. In general,
Open Access PLAN DESIGN
PLAN FEATURES Deductible (per plan year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family All covered expenses accumulate separately toward preferred or non-preferred Deductible. Unlesss
HPHC 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