Blue 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
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1 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 20%; physician $40, facility $50 Hospital/$40, Physician's office: PCP/$25, Specialist/ $40, facility $50 Hospital/$100, Physician's Office/$20, Facility/$100 Hospital/$100, Physician's Office/$20, Facility/$100 Ambulance No copayment if service is provided by admitting hospital. $35/trip $100/trip $50/trip $100/trip $100/trip Emergency Room $60 or $70/visit No copayment. $100/visit $75/visit $100/visit $100/visit Urgent Care $30 or $40 per outpatient visit $35/visit $25/visit $35/visit $35/visit Skilled Nursing Facility Authorization Required. No cost up to 365 benefit days. No cost: 45 days per admission up to a maximum of 360 lifetime limit No cost up to 45 days No cost up to 50 days No cost up to 45 days Hospice No cost; unlimited No cost; 210 days No cost; 210 days No cost; 210 days No cost; unlimited Page 1
2 E M P I R E P L A N Blue Cross (Hospital) United HealthCare (Medical) PHYSICIAN SERVICES Office Visit $25/visit; $5 PCP sick $25/visit; $10 PCP sick visits for children to ; no cost for well visits for children to age age 26, no cost annual child care 26, Well Child $0 exam or well child, no cost for well child visits Specialty Office Visit $40/visit $40/visit Annual Routine Physical No Cost No Cost No cost No Cost Allergy Testing / Treatment Contact carrier Contact carrier Contact carrier Contact carrier Chiropractic $40/visit $40/visit Family Planning $25/visit PCP, $40/visit specialist $25/visit PCP, $40/visit specialist Infertility Services $30 or $40 Outpatient ; no cost at designated Center of Excellence; $50,000 lifetime maximum Applicable physician/facility copayment $25/visit PCP, $40/visit specialist (physician's office), $100/visit (outpatient surgery center) Page 2
3 Contraceptive Drugs/ Devices No copayment for certain FDA approved medications and devices. Applicable prescription copay applies No cost No cost Applicable prescription copay applies WOMEN'S HEALTH CARE Pap Tests $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost No cost Mammograms $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost for routine visit No cost Pre/Post Natal $20 per visit No cost No cost $20/initial visit only No cost Bone Density Tests $30 or $40/outpatient visit $20 per visit No cost for routine visit No cost No cost No cost DIAGNOSTIC / THERAPEUTIC SERVICES X-Rays $30 or $40/outpatient visit $40/visit $25/visit Lab Tests $30 or $40/outpatient visit No cost No cost No cost $10/visit Page 3
4 Pathology No Cost No cost No cost No cost $10/visit EKG/EEG $30 or $40/outpatient visit No cost $25/visit Radiation / Chemo No Cost No cost Radiation $25/visit/Chemo $50 Radiation $40/visit; Chemotherapy $40/visit MENTAL HEALTH / SUBSTANCE ABUSE Inpatient Mental Health No cost; unlimited when medically necessary No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Mental Health ; unlimited when medically necessary $40/visit; unlimited $25/visit (individual or group); unlimited ; unlimited ; unlimited Page 4
5 Inpatient Drug / Alcohol Rehab No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited No cost; unlimited Outpatient Drug / Alcohol Rehab to approved program; unlimited when medically necessary $25/visit; unlimited $25/visit; unlimited ; unlimited ; unlimited PRESCRIPTION DRUGS Prescription Drugs *Note: 3-tier system (generic, preferred brandname drugs, and nonpreferred brand-name drugs) Mail order OR retail pharmacy, 30 day supply: $5, $25, or $45. Mail order or network pharmacy day supply: $10, $50, or $90. Pharmacy day supply: $5, $50, or $90. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name co-payment plus the difference in cost between the brand-name drug and its generic equivalent. 30 days retail: $10/$30/$ days mail order: $20/$60/$100. Open formulary. 30 days retail: $10/$30/$ days mail order: $25 generic/$75 brand/$125 nonformulary. Open formulary 30 days retail: $5/$30/$ days mail order: $12.50/$75/$ days retail: $5/$30/$ days mail order:$12.50/$75/$150 MISCELLANEOUS Centers of Excellence for Cancer and/or Transplant No cost at designated Centers of Excellence. Precertification required. N/A N/A N/A N/A Page 5
6 Diabetic Supplies No cost. Call HCAP for Diabetic Shoes $500 annual max $25/item; 30 day supply, Diabetic shoes 50% coinsurance $25 copayment per boxed item/31 day supply, Diabetic shoes 50% coinsurance $20/item, Diabetic shoes not covered $20/item, Diabetic shoes - one pair/year when medically necessary Home Health Care No cost. Call HCAP for Contact carrier Contact carrier Contact carrier, max 40 visits Durable Medical Equipment No cost. Call HCAP for 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Orthotics Paid in full/no copayment 50% coinsurance 50% coinsurance 20% coinsurance No cost Prosthetics Paid in full/no copayment 50% coinsurance 50% coinsurance 20% coinsurance No cost Rehabilitative Care (PT, OT, Speech) Inpatient: no cost; for PT following surgery or hospitalization Inpatient: no cost up to 60 days. Outpatient: $40/visit up to 30 visits combined for: PT, Speech and OT Inpatient: no cost, two month max; Outpatient: $40/visit up to 30 visits Inpatient: no cost up to 45 days. Outpatient: ; max 20 visits. Inpatient: No cost up to 45 days. Outpatient: up to 20 visits per year Page 6
7 Alternative Medicine: Nutrition, Acupuncture, Massage Therapy Discount for network provider Contact carrier - Discounts available Each policy receives $100 to spend on health, wellness, and fitness programs. Contact for additional programs. $300 Wellness card allowance for use at Contact for additional programs. $275 Wellness card allowance for use at Contact for additional programs. Dental (preventive) Not covered $40/when associated with disease or injury $25/visit for children up to 19 Preventive: 20% discount at select providers; free second annual exam $50/cleaning; 20% discount on additional services at select providers Hearing Aids Non participating provider: up to $1500 per aid per ear every 4 years (every 2 years for children). Covered in full every three years for children Not covered to age 19. Discounts Available at select providers Discounts Available at select providers Vision (routine) Not covered $40/exam associated with disease or injury. $25/exam every 24 months VisionPlus Program $10/visit once/year. Page 7
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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
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
Our service area includes the following county in: Florida: Miami-Dade.
2018 SUMMARY OF BENEFITS Overview of your plan Medica HealthCare Plans MedicareMax (HMO) H5420-001 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
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
Medical 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
Our service area includes the following county in: Delaware: New Castle.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H3113-011 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
Select 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
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
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
Summary 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
For Large Groups Health Benefit Single Plan (HSA-Compatible)
Financial Features (DED 1 ) (PBP 2 ) (DED is the amount the member is responsible for before Florida Blue pays) Out-of-Network Inpatient Hospital Facility Services Per Admission (PAD) Coinsurance (Coinsurance
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
Illustrative Benefits, Value Added Services and Premiums are effective January 1, 2016 through December 31, 2016
PLAN FEATURES Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) Network & Out-of-Network Providers $0 Member Coinsurance N/A Applies to all expenses unless otherwise stated.
SUMMARY OF BENEFITS 2009
HEALTH NET VIOLET OPTION 1, HEALTH NET VIOLET OPTION 2, HEALTH NET SAGE, AND HEALTH NET AQUA SUMMARY OF BENEFITS 2009 Southern Oregon Douglas, Jackson, and Josephine Counties, Oregon Benefits effective
Irvine 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
Summary of Benefits for Anthem MediBlue Dual Advantage (HMO SNP)
Summary of Benefits for Available in: Select Counties* in Maine *See Page 2 for a list of counties. Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits