AKIN Summary of Benefits
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1 AKIN Summary of Benefits
2 COST SHARE AKIN/ SUMMARY OF BENEFITS Annual Limits 2,500,000 2,500,000 1,000,000 Deductible The amount you owe for certain health care services, as indicated below. 2,500 Individual 5,000 Family 5,000 Individual 10,000 Family No Deductible Coinsurance - Your share of costs on a covered service - WellAway s share of costs on a covered service, after deductible and copay 20% 50% 50% 20% Annual out-of-pocket maximum This amount is the maximum you will pay each benefit period. Deductibles, coinsurance and co-payments are included in reaching this amount. 5,000 Individual 10,000 Family 10,000 Individual 20,000 Family No Out-of-Pocket Maximum HOSPITALIZATION Hospitalization (inpatient care) after deducible Rehabilitative services (inpatient care) after deducible Physician services (inpatient care) after deducible Psychiatric hospitalization 50% after deducible in Preferred Facility Emergency medical transportation 105 copay** 105 copay** WELLNESS CARE Percentage refers to WellAway s share of costs on a covered service after your deductible and copay Routine physical exams 1,000 limit per policy year Cancer screening (mammogram, pap test, prostate) 1,000 limit per policy year ** No deductible applies WellAway AKIN 2
3 AKIN/ SUMMARY OF BENEFITS PRESCRIPTION DRUGS Percentage refers to WellAway s share of costs on a covered service after your deductible and copay Preventive (e.g. oral contraceptives) Generic 10 copay** Brand 25 copay** Non-preferred brands 55 copay** Specialty (purchase from specialty pharmacy) 105 copay** MATERNITY CARE (90 day waiting period) Percentage refers to WellAway s share of costs on a covered service after your deductible and copay Prenatal and postnatal consultations after deductible Labor and delivery - hospital stay after deductible Birthing center after deductible Newborn care after deductible Congenital anomaly (e.g. cleft lip/ palate) after deductible Infertility treatment Sterilization (e.g. tubal ligations and vasectomies) after deductible ** No deductible applies WellAway AKIN 3
4 OUTPATIENT CARE AKIN/ SUMMARY OF BENEFITS Urgent care center 55 copay** 105 copay** Emergency room (waived with hospital admission) 255 copay** 255 copay** Outpatient hospital facility & surgical care after deductible Skilled nursing facility (limited to 20 visits) 255 copay per day General consultation / primary care visit 25 copay** Specialist consultation 45 copay** Psychiatric consultation (limited to 20 visits per year) 45 copay** Laboratory tests (independent clinical lab) 55 copay then Basic radiology (x-ray, ultrasound) 55 copay then Advanced radiology (MRI, CT, MRA) 105 copay** Durable medical equipment after deductible Rehabilitation and habilitation services 35 copay** Physical & speech therapy, spinal manipulation Cancer treatment, drugs & reconstructive surgery after deductible after deductible Dialysis after deductible EVACUATION & REPATRIATION Medical evacuation Transfer to the nearest medical facility if the treatment the member needs is not available locally. Medical repatriation members can return to their country of origin to be treated as long as physically and medically stable. up to 120,000 Limit per covered person, per benefit period up to 50,000 Lifetime limit per covered person ** No deductible applies WellAway AKIN 4
5 AKIN/ SUMMARY OF BENEFITS CHILD WELLNESS CARE Routine child exams & immunizations Annual routine tests Routine dental exams for children under 19 Eye exams for children under 19 Eye glasses for children under 19 AKIN Optional Coverage DENTAL AND VISION COVERAGE (OPTIONAL) FIRST YEAR SECOND YEAR THIRD YEAR Maximum benefit 3,500 per policy year Basic (routine) 65% 90% Deductible 100 lifetime Major restorative 25% 50% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Orthodontic treatment (covered for children under the age of 19-1,200 lifetime maximum per child, 600 annual limit) 10% 25% 50% Vision Care Routine vision exam 75, 10 copay (one vision exam per year - includes any fees for contact lense fittings) Lenses (single vision, bifocal, trifocal) Frames (limited to one per benefit period) Contact lenses (in lieu of frames) up to 225 (limited to one every 24 months) up to 200 up to 100 IMPORTANT NOTE: This product does not meet Minimum Essential Coverage. If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations, and exclusions of coverage. All benefits are subject to Usual Reasonable and Customary Fees (UCR). All benefits reflected in USD. WellAway products are not limited to French nationals and may be purchased by other expat nationalities inbound to the USA. WellAway insurance benefits act as a Top Up Plan for those French members that have selected La Caisse des Francis de L etranger (CFE) while living outside of France. CFE reimbursement are based on the French health System fee schedules and may assist in covering all or part of your co-payments while in the USA. If you are a CFE member and require information about its benefits and fee schedules, please contact the CFE directly. WellAway AKIN 5
6 This material is provided for informational purposes only and is subject to change. The information contained in this summary of benefits does and will not affect, modify or supersede in any way the policy terms and conditions. This document shall not bind WellAway Limited or require WellAway Limited to offer or write any insurance at any particular rate or to any particular group or individual. The actual premium and benefits are governed by your policy documents. All benefits are subject to exclusions and limitations. To ensure you have all the information you need before purchasing one of our products, we recommend you consult with your independent medical, legal and/or tax advisors. If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. Products and services may not be available in all jurisdictions and are expressly excluded where prohibited by applicable law. The contents of this material are the exclusive intellectual property of WellAway Limited. No reproduction, changes or copying is possible without the consent of WellAway Limited. The WellAway name, brand and logos are the registered marks of WellAway Limited and WellAway SA, Hamilton, Bermuda. WellAway AKIN 6
7 CONTACT US Bermuda: UK: France: Belgium: Skype: info@wellaway.com WellAway Limited Canon s Court, 22 Victoria Street Hamilton HM 12, Bermuda Rev. 02/2018
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Important Questions Answers Why this Matters:
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No. What is not included in the out of pocket limit? Even though you pay these expenses, they don t count toward the out-of-pocket limit.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan s summary plan description at www.psbenefitstrust.com or by calling (206) 441-7574,
BridgeSpan Health Company: BridgeSpan Silver HDHP 2000 MyChoice Northwest
BridgeSpan Health Company: BridgeSpan Silver HDHP 2000 MyChoice Northwest Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 12/31/2016 Coverage for: Individual
PLAN DESIGN AND BENEFITS - PA POS COST-SHARING 3.4 ($1,500 DED) PARTICIPATING PROVIDERS. $1,500 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $3,000 Individual $6,000 Family 50% $6,000 Individual $12,000 Family Amounts over the Recognized Charge, failure to pre-certification
$7,000 Family. $7,150 Individual $14,300 Family
PLAN DESIGN AND BENEFITS - MD Silver HNOnly SJ 3500 100% (2017) MD Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
PLAN DESIGN AND BENEFITS - Tx OAMC 3000 HSA 100% 08 PREFERRED CARE
Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 09/01/2008 PLAN FEATURES NON- Deductible (per calendar year) $3,000 Individual $6,000 Individual $6,000 Family $12,000
Nortel FLEX 2012 Enrollment. Summary of Health Benefits
Nortel FLEX 2012 Enrollment Summary of Health Benefits 1 Summary of Health Benefits Medical Network Area The chart below outlines the main features of the Medical Plan options available to you if you live
BridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO
BridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at www.bridgespanhealth.com.
Traditional Choice (Indemnity) (08/12)
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Not Applicable Not Applicable $500 Individual (2-member maximum) Unless otherwise indicated, the Deductible must be
$3,000 Individual $6,000 Family All covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) OUT-OF- Primary Care Physician Selection Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible
$8,000 Family. $6,000 Individual $12,000 Family
PLAN DESIGN AND BENEFITS - FL Silver HNOnly 4000 100 (2016) FL Group Business 2-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
PLAN DESIGN AND BENEFITS - PA POS COST-SHARING NO-REFERRAL 4.4 ($2,000 DED) $2,000 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $4,000 Individual $8,000 Family 50% $8,000 Individual $16,000 Family Amounts over the Recognized Charge, failure to pre-certification