Retirees with Medicare (RETIREMENT DATE BEFORE March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2017
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- Karen Crystal Ferguson
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1 Network Eligible OGB Members Pelican HRA1000 Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers (retirement date BEFORE 3/1/2015) Magnolia Local Plus Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers (retirement date BEFORE 3/1/2015) Network Non-Network Network Non-Network You Pay You Pay You You + 1 (Spouse or child) You + Children You + Family $2,000 $4,000 $0 $4,000 $8,000 $0 $4,000 $8,000 $0 $4,000 $8,000 $0 HRA dollars will reduce this amount Out-of-Pocket Maximum You $5,000 $10,000 $1,000 You + 1 (Spouse or child) You + Children $10,000 $20,000 $2,000 $10,000 $20,000 $3,000 You + Family $10,000 $20,000 $3,000 State Funding The Plan Pays The Plan Pays You You + 1 (Spouse or child) You + Children You + Family $1,000 $2,000 $2,000 $2,000 Funding not applicable to Pharmacy Expenses. Not Available Physicians The Plan Pays The Plan Pays Primary Care Physician or Specialist Office - Treatment of illness or injury subject to subject to a $25 PCP or $50 SPC 60
2 Magnolia Open Access Magnolia Local Vantage Medical Home HMO Blue Cross and Blue Shield of Louisiana Preferred Care Provider & Blue Cross National Providers (retirement date BEFORE 3/1/2015) Blue Cross and Blue Shield of Louisiana Community Blue & Blue Connect (retirement date BEFORE 3/1/2015) Tier I (Affinity Health Network AHN and standard) and Out-of-Network Network Non-Network Network Non-Network Network Non-Network You Pay You Pay You Pay $300 $0 $0 $1,500 $600 $0 $0 $3,000 $900 $0 $0 $4,500 $900 $0 $0 $4,500 Out-of-Pocket Maximum $1,000 $1,000 No Maximum $2,300 individual; plus $2,300 per additional person up to 2; plus $2,000 per additional person up to 2 additional people; $12,700 for a family of 5+ $2,000 $2,000 No Maximum $3,000 $3,000 No Maximum $3,000 $3,000 No Maximum Not Available Not Available Not Available subject to subject to a $25 PCP or $50 SPC a $10 AHN/$20 PCP or $35 AHN/$45 SPC 50% coverage; subject to Out-of- Network 61
3 Pelican HRA1000 Magnolia Local Plus Network Non-Network Network Non-Network Physicians The Plan Pays The Plan Pays Maternity Care (prenatal, delivery and postpartum) subject to subject to after a $90 per pregnancy Physician Furnished in a Hospital Visits; surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist. subject to subject to 100% coverage Preventative Care Primary Care Physician or Specialist Office or Clinic For a complete list of benefits, refer to the Preventive and Wellness/ Routine Care in the Benefit Plan not subject to 100% of fee schedule amount. Plan participant pays the difference between the billed amount and the fee schedule amount; not subject to 100% coverage Physician for Emergency Room Care subject to subject to 100% coverage 100% coverage Allergy Shots and Serum Copayment is applicable only to office subject to subject to a $25 PCP or $50 SPC per office ; shots and serum 100% Outpatient Surgery/ When billed as office s subject to subject to after a $25 PCP or $50 SPC per office Outpatient Surgery/ When billed as outpatient surgery at a facility subject to subject to 100% coverage Hospital The Plan Pays The Plan Pays Inpatient Inpatient care, delivery and inpatient short-term acute rehabilitation services subject to subject to after a $100 per day max $300 per 62
4 Magnolia Open Access Magnolia Local Vantage Medical Home HMO Network Non-Network Network Non-Network Network Non-Network subject to subject to after a $90 per pregnancy 100% coverage after a $10 AHN/$20 per pregnancy subject to subject to 100% coverage 100% coverage not subject to subject to 100% coverage 100% coverage subject to subject to 100% coverage 100% coverage 100% coverage subject to subject to a $25 PCP or $50 SPC per office ; shots and serum 100% 80% coverage subject to subject to after a $25 PCP or $50 SPC per office a $10 AHN/$20 PCP or $35 AHN/$45 SPC office per subject to subject to 100% coverage 100% coverage subject to subject to after a $100 per day max $300 per a $50 AHN/$100 per day max $150 AHN/$300 per 63
5 Pelican HRA1000 Magnolia Local Plus Network Non-Network Network Non-Network Hospital The Plan Pays The Plan Pays Outpatient Surgery/ Hospital / Facility subject to subject to after a $100 facility Emergency Room - Hospital (Facility) Treatment of an emergency medical condition or injury subject to subject to $150 $150 ; waived ; waived if admitted if admitted Behavioral Health The Plan Pays The Plan Pays Mental Health and Substance Abuse Inpatient Facility subject to subject to after a $100 per day max $300 per Mental Health and Substance Abuse Outpatient Visits - Professional subject to subject to after a $25 per Other Coverage The Plan Pays The Plan Pays Outpatient Acute Short- Term Rehabilitation Physical Therapy, Speech Therapy, Occupational Therapy, Other short term rehabilitative services subject to subject to after a $25 per Chiropractic Care subject to subject to after a $25 per Hearing Aid Not covered for individuals age eighteen (18) and older subject to 80% coverage Vision Exam (routine) Urgent Care Center subject to subject to a $50 Home Health Care subject to subject to 100% coverage 64
6 Magnolia Open Access Magnolia Local Vantage Medical Home HMO Network Non-Network Network Non-Network Network Non-Network subject to subject to after a $100 facility a $50 AHN/$100 subject to ; $150 ; waived if admitted subject to ; $150 ; waived if admitted $150 ; waived if admitted $150 ; waived if admitted a $150 ; waived if admitted a $150 per ; not subject to subject to subject to after a $100 per day max $300 per a $50 AHN/$100 per day max $150 AHN/$300 per subject to subject to after a $25 a $10 AHN/$20 PCP or $35 AHN/$45 SPC subject to subject to after a $25 a $10 AHN/$20 subject to subject to after a $25 a $20 PCP subject to subject to 80% coverage 80% coverage after a $35 AHN/$45 subject to subject to a $50 per after a $50 100% coverage 100% coverage 65
7 Pelican HRA1000 Magnolia Local Plus Network Non-Network Network Non-Network Other Coverage The Plan Pays The Plan Pays Skilled Nursing Facility subject to subject to after a $100 per day max $300 per Hospice Care subject to subject to 100% coverage Durable Medical Equipment (DME) - Rental or Purchase subject to subject to 80% coverage of the first $5,000 allowable; 100% in excess of $5,000 per plan year; Transplant subject to 100% coverage Pharmacy You Pay You Pay Tier 1 - Generic 50% up to $ % up to $30 1 Tier 2 - Preferred 50% up to $55 1,2 50% up to $55 1,2 Tier 3 - Non-Preferred 65% up to $80 1,2 65% up to $80 1,2 Tier 4 - Specialty 50% up to $80 1,2 50% up to $80 1,2 90 day supply for maintenance drugs from mail order OR at participating 90-day retail network pharmacies 2.5 times the cost of applicable maximum 2.5 times the cost of applicable maximum After the out-of-pocket threshold amount of $1,500 is met by you and/or your covered dependent(s): Tier 1 - Generic $0 1 $0 1 Tier 2 - Preferred $20 1,2 $20 1,2 Tier 3 - Non-Preferred $40 1,2 $40 1,2 Tier 4 - Specialty $40 1,2 $40 1,2 NOTE: Prior Authorizations and Visit Limits may apply to some benefits - refer to your Plan Document for details. This comparison chart is a summary of plan features and is presented for general information only. It is not a guarantee of coverage. 66
8 Magnolia Open Access Magnolia Local Vantage Medical Home HMO Network Non-Network Network Non-Network Network Non-Network subject to subject to after a $100 per day max $300 per 100% coverage after $50 AHN/$100 per day max $150 AHN/$300 per 100% coverage 100% coverage subject to subject to 80% coverage of the first $5,000 allowable; 100% in excess of $5,000 per plan year 80% coverage of the first $5,000 allowable; 100% in excess of $5,000 per plan year subject to subject to 100% coverage $100 per day, max $300 per You Pay You Pay You Pay 50% up to $ % up to $30 1 Generics Tier 2 - Non-Preferred Tier 1 - Preferred Generics $5 3 $ % up to $55 1,2 50% up to $55 1,2 Tier 3 - Preferred Brand $50 2,3 65% up to $80 1,2 65% up to $80 1,2 Tier 4 - Non-Preferred Brand $80 2,3 50% up to $80 1,2 50% up to $80 1,2 Tier 5 - Specialty $150 2,3 2.5 times the cost of applicable maximum 2.5 times the cost of applicable maximum Tier I Preferred Generics: $0 AHN copay; Tiers 2-4: 3 copays; Tier 5 Specialty: 90-day mail-order not available After the out-of-pocket threshold amount of $1,500 is met by you and/or your covered dependent(s)*: $0 1 $0 1 N/A $20 1,2 $20 1,2 N/A $40 1,2 $40 1,2 N/A $40 1,2 $40 1,2 N/A 1 Prescription drug benefit - 31-day fill 2 Member who chooses brand-name drug for which approved generic version is available pays cost difference between brand-name drug & generic drug, plus copay for brand-name drug; cost difference does not apply to $1,500 out-of-pocket threshold (if applicable). 3 Prescription drug benefit - 30-day fill * $1,500 threshold does not apply to Vantage Medical Home HMO pharmacy benefits 67
Retirees with Medicare (RETIREMENT DATE ON or AFTER March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2017
Pelican HRA1000 Magnolia Local Plus Network Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers Blue Cross and Blue Shield of Louisiana Preferred Care Providers
Retirees with Medicare (RETIREMENT DATE ON or AFTER March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2019
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Retirees with Medicare (RETIREMENT DATE BEFORE March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2019
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NON- LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes Deductible, Coinsurance, Copays and Precertification
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/fi or by calling 1-800-542-9402.
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Summary 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 Pennsylvania Turnpike Commission: Highmark PPO Blue Coverage for: Individual/Family
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2019
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Highmark West Virginia: my Blue Access WV EPO Silver 3500-2 Free PCP Visits
$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
Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.denverhealthmedicalplan.org or by calling 1-800-700-8140.
Your Summary of Benefits
Educational Purchasing Council - Madison-Plains Lumenos Health Reimbursement Accounts (with Copay) Effective: October 1, 2018 Employer Health Reimbursement Account Contribution: Single: $4,000 Family:
Balance 3 up to Allowed Amount 4 after BCBSF pays up to $50. $0 CYD % Coinsurance 6
Understanding Your Share for Covered Services This health insurance policy 1 provides you with routine health care services, such as physician office services, as well as basic protection against major
Important Questions Answers Why this Matters: What is the overall deductible? $0 Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsga.com/usg or by calling 1-800-424-8950. Important
Your Plan: Anthem Bronze PPO 6000/0%/6000 w/hsa Your Network: Prudent Buyer PPO
Your Plan: Anthem Bronze PPO 6000/0%/6000 w/hsa Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does
Important 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
Medical Plan. Comparison
Medical Plan Comparison 2018 ATTENTION: This Medical Plan Comparison is considered a summary of material modifications (SMM) to one or more of the WHOI benefit plans. It contains a summary of important
2016 HealthFlex Plan Comparison: PPO B1000 with HRA and CDHP C2000 with HRA
Caring For Those Who Serve 1901 Chestnut Avenue Glenview, Illinois 60025-1604 1-800-851-2201 www.gbophb.org 2016 HealthFlex Plan Comparison: PPO B1000 with HRA and CDHP C2000 with HRA Please note: This
Your Plan: BCBSHP Essential DirectAccess gjia Your Network: Blue Open Access POS 10NR S-OAP2 4K/20 6.3K p1
Your Plan: BCBSHP Essential DirectAccess gjia Your Network: Blue Open Access POS 10NR S-OAP2 4K/20 6.3K p1 This summary of benefits is a brief outline of coverage, designed to help you with the selection
HealthTrust: LUMENOS $2500 Coverage Period: 07/01/ /30/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-888-224-4896. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-421-1880. Important Questions
Anthem Blue Cross and Blue Shield Your Plan: Lumenos Health Savings Account (HSA-Compatible) Plan $ /20 Your Network: PPO
Anthem Blue Cross and Blue Shield Your Plan: Lumenos Health Savings Account (HSA-Compatible) Plan $3500 80/20 Your Network: PPO This summary of benefits is a brief outline of coverage, designed to help
Important Questions Answers Why this Matters:
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? $1,500 single / $3,000 family
Blue Care Elect $250 Deductible MIIA Coverage Period: on or after 07/01/2015
Blue Care Elect $250 Deductible MIIA Coverage Period: on or after 07/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This
Anthem Blue Cross Blue Shield: Anthem Silver DirectAccess - cbka Coverage Period: 01/01/ /31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-888-231-5046. Important Questions
Your Plan: Anthem Silver Blue Access Choice 5000/20%/6600 Your Network: Blue Access Choice
Your Plan: Anthem Silver Blue Access Choice 5000/20%/6600 Your Network: Blue Access Choice This summary of benefits is a brief outline of coverage, designed to help y ou with the selection process. This
Important Questions Answers Why this Matters: What is the overall deductible? $0 Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsga.com/bor or by calling 1-800-424-8950. Important
$4,800.00/ individual. $9,600.00/family
Medical Plans Please note, this brochure provides an overview of certain health care plan provisions under the Adobe Systems Incorporated Group Welfare Plan. It is not intended to be a complete description
Cost if you use a Non-Network Provider. Cost if you use an In-Network Provider. Covered Medical Benefits
Anthem Blue Cross California State University Risk Management Authority Your Plan: Custom Premier HMO 20/200 admit/100 OP (Custom Rx $5/$20/$60/20%) Your Network: California Care HMO This summary of benefits
CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) CERTIFICATE RIDER
Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152 CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) CERTIFICATE RIDER No. CR7BIASO5-3 Policyholder:
Your Plan: 2018 HMO Plan (2940) Your Network: California Care HMO
Anthem Blue Cross Your Plan: 2018 HMO Plan (2940) Your : California Care HMO ACWA JPIA C00361 This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.soundhealthwellness.com or by calling 1-800-225-7620.
Anthem Blue Cross Your Plan: Modified Premier HMO 15/100% (Essential formulary $5/$15/$25/$45/30%) Your Network: California Care HMO
Anthem Blue Cross Your Plan: Modified Premier HMO 15/100% (Essential formulary $5/$15/$25/$45/30%) Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to
Summary of Benefits Custom HMO Zero Admit 10
Summary of Benefits Custom HMO Zero Admit 10 City of Delano Effective July 1, 2019 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of
Summary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2018-06/30/2019 Allegheny County Schools Health Insurance Consortium: Community Blue Flex Coverage for: Individual/Family
Coverage for: Individual and Family Plan Type: POS. Important Questions Answers Why this Matters: $250 member / $500 two-person /
Blue Choice New England Plan 2 Berkshire Health Group Coverage Period: on or after 07/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family