BluePreferred PPO Standard Silver $3,500 Coverage Period: 01/01/ /31/2019
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1 Summary of Benefits and Coverage:What This Plan Covers & What You Pay For Covered Services BluePreferred PPO Standard Silver $3,500 Coverage Period: 01/01/ /31/2019 Coverage for: Individual Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can see the Glossary at or call to request a copy. For more information about your coverage, or to get a copy of the complete terms of coverage, please Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? In-Network: $3,500 individual/ $7,000 family; Out-of-Network: $7,000 individual/ $14,000 family. Yes, all In-Network preventive care services, as well as the following (non-hospital facilities only, when applicable): Primary care, Specialist, Retail health, Diagnostic testing, Generic drugs, Urgent care, Mental Health office, Home health, Rehabilitation services, Durable medical equipment, Hospice. Generally, you must pay all the costs from provider up to the deductible amount before this plan begins to pay. If you have other family member(s) on the plan, each family member may need to meet their own individual deductible, OR all family members may combine to meet the overall family deductible before the plan begins to pay, depending upon plan coverage. Please refer to your contract for further details. This plan covers some items and services even if you haven t yet met the deductible amount. But, a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? Yes. Prescription Drug: $250 individual. Medical and Prescription Drug combined: In-Network: $7,600 individual/ $15,200 family; Out-of-Network: $15,200 individual/ $30,400 family. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay in a plan year for covered services. If you have other family member(s) on the plan, each family member may need to meet their own out-of-pocket limits, OR all family members may combine to meet the overall family out-of-pocket limit, depending upon plan coverage. Please refer to your contract for further details. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. SBC ID: SBC MANAPNDBN04RXXDBN16N Page 1 of 12
2 What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do I need a referral to see a specialist? Premiums, balance-billed charges, and health care this plan does not cover. Yes. See or call for a list of provider network. No. Even though you pay these expenses, they don't count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions & Other Important Information Primary care to treat an injury or illness Provider: $40 copay per Hospital Facility: Provider & Hospital Facility: If a service is rendered at a Hospital Facility, the additional Facility charge may apply If you a health care provider s office or clinic Specialist Retail Health Clinic Provider: $80 copay per Hospital Facility: $40 copay per Provider & Hospital Facility: If a service is rendered at a Hospital Facility, the additional Facility charge may apply Preventive care/screening/ immunization No Charge Deductible, then No Charge Some services may have limitations or exclusions based on your contract SBC ID: SBC MANAPNDBN04RXXDBN16N Page 2 of 12
3 Common Medical Event If you have a test Services You May Need Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) In-Network Provider (You will pay the least) LabTest: Non-Hospital: $50 copay per Hospital: $50 copay per XRay: Non-Hospital: $70 copay per Hospital: $70 copay per Non-Hospital: $250 copay per Hospital: $250 copay per What You Will Pay Out-of-Network Provider (You will pay the most) LabTest: Non-Hospital: Hospital: Deductible, then 40% of XRay: Non-Hospital: Hospital: Deductible, then 40% of Non-Hospital: Deductible, then 40% of Hospital: Deductible, then 40% of Generic drugs $15 copay Paid As In-Network If you need drugs to treat your illness or condition Preferred brand drugs Deductible, then $50 copay More information about prescription drug coverage is available at Non-preferred brand drugs Preferred Specialty drugs Non-preferred Specialty drugs Deductible, then $70 copay Deductible, then $150 copay Deductible, then $150 copay Paid As In-Network Paid As In-Network Not Covered Not Covered Limitations, Exceptions & Other Important Information For all prescription drugs: Prior authorization may be required for certain drugs; No Charge for preventive drugs or contraceptives; Copay applies to up to 30-day supply; Up to 90-day supply of maintenance drugs is 2 copays; Specialty Drugs: Participating Providers: covered when purchased through the Exclusive Specialty Pharmacy Network Non-Participating Providers: Not Covered If you have outpatient Facility fee (e.g., ambulatory surgery center) Non-Hospital & Hospital: Non-Hospital & Hospital: SBC ID: SBC MANAPNDBN04RXXDBN16N Page 3 of 12
4 Common Medical Event surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse services If you are pregnant Services You May Need Physician/surgeon fees Emergency room care Emergency medical transportation In-Network Provider (You will pay the least) Non-Hospital & Hospital: Deductible, then $350 copay per Deductible, then $350 copay per What You Will Pay Out-of-Network Provider (You will pay the most) Non-Hospital & Hospital: Paid As In-Network Paid As In-Network Urgent care $90 copay per Paid As In-Network Facility fee (e.g., hospital room) Physician/surgeon fee Outpatient services Inpatient services Office s Childbirth/delivery professional services Childbirth/delivery facility services Office Visit: $40 copay per No Charge Office Visit: Deductible, then 40% of Limitations, Exceptions & Other Important Information Limited to Emergency Services or unexpected, urgently required services; Additional professional charges may apply; Copay waived if admitted Prior authorization is required for air ambulance services, except when Medically Necessary in an emergency Limited to unexpected, urgently required services Prior authorization is required For treatment at an Outpatient Hospital Facility, additional charges may apply Prior authorization is required; Additional professional charges may apply For routine pre/postnatal office s only. For non-routine obstetrical care or complications of pregnancy, cost sharing may apply. SBC ID: SBC MANAPNDBN04RXXDBN16N Page 4 of 12
5 What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions & Other Important Information Home health care $50 copay per Prior authorization is required; 90 s/episode of care Rehabilitation services Provider: $50 copay per Hospital Facility: Provider & Hospital Facility: If a service is rendered at a Hospital Facility, the additional Facility charge may apply If you need help recovering or have other special health needs Habilitation services Skilled nursing care Provider: $50 copay per Hospital Facility: Provider & Hospital Facility: Prior authorization is required for Member age 21 and older; If a service is rendered at a Hospital Facility, the additional Facility charge may apply Prior authorization is required; 60 days/benefit period Durable medical equipment 20% of Prior authorization is required for specified services. Please see your contract. Hospice services Inpatient Care: No Charge Outpatient Care: No Charge Inpatient Care: Deductible, then 40% of Outpatient Care: Deductible, then 40% of Prior authorization is required; For Participating Providers and Non-Participating Providers (combined): Limited to a maximum 180-day Hospice Eligibility Period which includes a maximum of 60 days Inpatient Hospice Services per Hospice Eligibility Period Children's eye exam No Charge Member pays expenses in excess of the Pediatric Vision of $40 Limited to Members up to age 19; Limited to 1 /benefit period If your child needs dental or eye care Children's glasses No Charge for glasses/lenses Allowances available for glasses/lenses Limited to Members up to age 19; Limited to 1 set of glasses/ lenses per benefit period SBC ID: SBC MANAPNDBN04RXXDBN16N Page 5 of 12
6 Common Medical Event Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Children's dental check-up No Charge 20% of Limitations, Exceptions & Other Important Information Limited to Members up to age 19; Limited to 2 s/benefit period Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Hearing aids Routine foot care Bariatric surgery Infertility treatment Weight loss programs Cosmetic surgery Long-term care Dental care (Adult) Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Abortion, except in limited circumstances Coverage provided outside the United States. Routine eye care (Adult) See Chiropractic care Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: District of Columbia Healthcare Finance, or call Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: District of Columbia Healthcare Finance, or call Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. SBC ID: SBC MANAPNDBN04RXXDBN16N Page 6 of 12
7 To see examples of how this plan might cover costs for a sample medical situation, see the next section. SBC ID: SBC MANAPNDBN04RXXDBN16N Page 7 of 12
8 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe's type 2 Diabetes (a year of a routine in-network care of a well-controlled condition) Mia's Simple Fracture (in-network emergency room and follow up care) The plan s overall deductible $3,500 Specialist Copayment $80 Hospital (facility) Coinsurance 20% Other Copayment $50 The plan s overall deductible $3,500 Specialist Copayment $80 Hospital (facility) Coinsurance 20% Other Coinsurance 20% The plan s overall deductible $3,500 Specialist Copayment $80 Hospital (facility) Copayment $350 Other Copayment $70 This EXAMPLE event includes services like: Specialist office s (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $3,500 Copayments $200 Coinsurance $1,314 What isn t covered Limits or exclusions $10 The total Peg would pay is $5,024 This EXAMPLE event includes services like: Primary care physician office s (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $3,090 Copayments $1,005 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Joe would pay is $4,095 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,900 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,900 The plan would be responsible for the other costs of these EXAMPLE covered services. SBC ID: SBC MANAPNDBN04RXXDBN16N Page 8 of 12
9 Notice of Nondiscrimination and Availability of Language Assistance Services o o o o If you need these services, please call To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office Civil Rights Coordinator, Corporate Office of Civil Rights Page 9 of 12
10 Foreign Language Assistance አማርኛማሳሰቢያ ይህማስታወቂያስለመድንሽፋንዎመረጃይዟል ከተወሰኑቀነገደቦችበፊትሊፈጽሟቸውየሚገቡነገሮች ሊኖሩስለሚችሉእነዚህንወሳኝቀናትሊይዝይችላል ይኽንመረጃየማግኘትእናያለምንምክፍያበቋንቋዎእገዛየማግኘትመብትአለዎት አባልከሆኑከመታወቂያካርድዎበስተጀርባላይወደተጠቀሰውየስልክቁጥርመደወልይችላሉ አባልካልሆኑደግሞወደስልክቁጥር ደውለውንእንዲጫኑእስኪነገርዎድረስንግግሩንመጠበቅአለብዎ አንድወኪልመልስሲሰጥዎ የሚፈልጉትንቋንቋ ያሳውቁ ከዚያምከተርጓሚጋርይገናኛሉ Page 10 of 12
11 हदय नदइसस चन मआपकब म कवर जक ब र मज नक रदगईह ह सकत ह कइसमम य तथयक उल खह औरआपक लएकस नयतसमयस म क भ तरक मकरन ज़रह आपक यहज नक र औरस ब धतसह यत अपन भ ष मन श कप न क अधक रह सदयक अपन पहच नपक प छ दएगएफ़ न न बरपरक लकरन च हए अयसभ ल गपरक लकरसकत हऔरजबतकदब न क लएनकह ज एतबतकस व दकत कर जबक ईएजटउतरद त उस अपन भ ष बत ए औरआपक य य क रस कन ट करदय ज एग ব ল লকনএইন শআপন র বম কভ রজস ক তথর য় ছ এরম ধপ ণত রখথ ক তপ র এব ন দত র খরম ধআপন কপদ প ন তহ তপ র বন খর চ ন জরভ ষ য়এইতথপ ওয় রএব সহ য়ত প ওয় র অ ধক রআপন রআ ছ সদস দর কত দরপ রচয়প র পছ নথ ক ন রকলকর তহ ব অ নর ন র কলক রপ তন বল পযঅ প কর তপ রন যখনক ন এ জউরদ বনতখনআপন র ন জরভ ষ রন মবল ন এব আপন কদ ভ ষ রস স য কর হ ব لام لا لا لاء لا Page 11 of 12
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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More information$350 individual/$700 family network. $700 individual/$1,400 family out-ofnetwork.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2018-03/31/2019 Gannon University: PPO Coverage for: Individual/Family Plan Type: PPO
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018 Community Value HMO (Silver) - 94% CSR Coverage for: Individual
More information$0 individual/$0 family network. $250 individual/$500 family out-ofnetwork.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Blue Shield: PPO Coverage for: Individual/Family Plan Type: PPO
More informationThe Harvard Pilgrim Best Buy ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Best Buy ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018 06/30/2019 Coverage for:
More informationYou don t have to meet deductibles for specific services. for specific services?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: State Health Benefits Program- NJ DIRECT15 (PPO) Coverage
More informationBest Buy HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HMO 500 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2018 03/31/2019 Coverage for: Individual + Family
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Blue Cross Blue Shield: Major Events Blue PPO 7350 a Community
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: State Health Benefits Program- NJ DIRECT 2030 (PPO) Coverage
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: State Health Benefits Program- NJ DIRECT 2035 (PPO) Coverage
More informationCoverage Period: 01/01/ /31/2019 Coverage for: Individual + Family Plan Type: POS
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Blue Cross and Blue Shield of North Carolina: Blue Value Catastrophic Coverage Period: 01/01/2019-12/31/2019
More informationHMO - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts HMO - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Coverage for: Individual + Family Plan Type:
More informationElevateHealth Gold 1000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
New Hampshire ElevateHealth Gold 1000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family
More informationStandard Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Standard Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan Type:
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/19 12/31/19
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/19 12/31/19 Toledo Electrical Welfare Fund : Plan M Medicare Supplement Coverage for: Individual/Family
More informationStandard Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Standard Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan Type:
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: State Health Benefits Program- HORIZON HMO Coverage for:
More informationCoverage Period: 01/01/ /31/2019 Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
BlueCare 1865 Coverage Period: 01/01/2019-12/31/2019 Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type: HMO
More information$300 person/$900 family
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 AeroVironment, Inc. Employee Benefit Plan: PPO Option Coverage for: Single
More informationCoverage Period: 01/01/ /31/2019 Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
myblue 1711S Coverage Period: 01/01/2019-12/31/2019 Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type:
More informationSummary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2017 06/30/2018 Johns Hopkins Student Health Program Coverage for: Individual and Family
More informationBest Buy HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HMO 2000 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 03/31/2018 Coverage for: Individual + Family
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: 7/1/2017 to 6/30/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 7/1/2017 to 6/30/2018 Long Beach Unified School District 1500/3000 Coverage for: Individual
More informationUnlimited person/unlimited family
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Cherokee County EPO Plan Employee Benefit Plan Coverage for: Single +
More informationSummary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2018 Community Preferred (Silver) Employer Coverage for: Individual
More informationCoverage for: Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2017-09/30/2018 Anthem Blue Cross: Select 80-G $30; Rx 10-35/200 Coverage for: Family
More informationCoverage for: Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2017-09/30/2018 Anthem Blue Cross: 100-C $20; Rx 15-50/200 Coverage for: Family Plan Type:
More informationCoverage for: Individual + Family Plan Type: POS
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 Blue Cross and Blue Shield of North Carolina: Blue Local Bronze 6750 with
More informationBlueSelect In-Network: $6,200 Per Person/$12,400 Family. Out-of- Network: $12,400 Per Person/$24,800 Family.
BlueSelect 1449 Coverage Period: 01/01/2019-12/31/2019 Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type:
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Blue Cross Blue Shield: my Direct Blue Conemaugh EPO 6950B Coverage
More informationCoverage Period: 01/01/ /31/2019 Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
BlueCare 1565 Coverage Period: 01/01/2019-12/31/2019 Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type: HMO
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services KS Select by Medica Bronze HSA
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationCoverage for: Single Enrollee Plan Type: TRAD/PPO. Important Questions Answers Why This Matters: $2,500/single Network $5,000/single Non-Network
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 STRS OHIO : Basic Plan with Medicare Part B Only Coverage for: Single
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Health Insurance Company: my Direct Blue Major Events EPO 7350
More informationBest Buy HSA HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HSA HMO 3100 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 03/31/2018 Coverage for: Individual +
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Health Insurance Company: my Direct Blue Lehigh Valley EPO 6950B
More informationYou don't have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services BlueCross and BlueShield of Nebraska : Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits
More informationThe HPHC Insurance Company PPO
Massachusetts The HPHC Insurance Company PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services MN Applause Bronze HSA
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationThe Harvard Pilgrim PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 12/01/2017 11/30/2018 Coverage for: Individual + Family
More informationCoverage Period: Beginning on or after 01/01/2019 Coverage for: Individual or Family Plan Type: EPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationImportant Questions Answers Why This Matters: What is the overall deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: MIDDLESEX COUNTY IMPROVEMENT AUTHORITY POS Coverage for:
More informationImportant Questions Answers Why This Matters:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 : Roper St. Francis Flex Plan Coverage for: Individual or Family Plan
More informationBlueSelect What is the overall deductible? In-Network: Not Applicable. Outof-Network: $500 Per Person.
BlueSelect 1535 Coverage Period: 01/01/2019-12/31/2019 Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual and/or Family Plan Type:
More informationThe Harvard Pilgrim HMO
Massachusetts The Harvard Pilgrim HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family
More informationBest Buy HSA HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HSA HMO 2000 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 03/31/2018 Coverage for: Individual +
More informationYou don t have to meet deductibles for specific services. for specific services? What is the out-of-pocket limit for this plan?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: State Health Benefits Program- OMNIA Health Plan Coverage
More informationCoverage for: Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2017-12/31/2017 Anthem Blue Cross: 2 Tier Anchor Bronze Coverage for: Family Plan Type:
More informationCoverage for: Individual + Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 UFCW & Participating Employers: Plan JSS2 Coverage for: Individual + Family
More informationThe Harvard Pilgrim Primary Choice HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Primary Choice HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018 06/30/2019 Coverage for: Individual
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 UFCW Self-Funded Comprehensive Medical Plan Two Coverage for: Participant
More informationCoverage Period: Beginning on or after 01/01/2018 Coverage for: Individual + Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Thrifty White Stores, Inc.- HSA PLAN Coverage Period: Beginning on or after 01/01/2018 Coverage for: Individual
More informationMaine's Choice HSA HMO 5000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Maine Maine's Choice HSA HMO 5000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan
More informationThe Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 12/01/2017 11/30/2018 Coverage for: Individual
More informationYou don't have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services BlueCross and BlueShield of Nebraska : Coverage for: Individual/Family Plan Type: QHDHP The Summary of Benefits
More informationImportant Questions Answers Why This Matters: What is the overall
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2017-06/31/2018 Horizon BCBSNJ: NEW JERSEY TRANSIT Coverage for: All Coverage Types Plan
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Highmark Delaware: Health Savings Embedded Blue EPO Silver 4450 HSA Coverage
More information$2,000/Individual, $4,000/Family per benefit period. What is the overall deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
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