Summary of Benefits Prominence HealthFirst Small Group Health Plan

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Summary of Benefits Prominence HealthFirst Small Group Health Plan"

Transcription

1 HealthFirst/ Calendar Year Deductible (CYD) 2 $1,000 Single / $3,000 Family Summary of Benefits $3,000 Single / $9,000 Family Coinsurance - Member responsibility 30% coinsurance 50% coinsurance Out-of-Pocket Maximum 3 - Deductibles, coinsurance and copays accrue toward the out-of-pocket maximum. Physician Office Visits $6,000 Single / $12,000 Family $18,000 Single / $36,000 Family Telemedicine services $25 copay Primary care practitioner (PCP) $25 copay Specialist office visit 4 $50 copay Charges in addition to the office visit copay may include In-office surgical procedure In-office injectable (excluding specialty drugs) There may be additional charges for other services in the provider s office. See this summary of benefits for details. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year; innetwork and out-of-network combined. Ambulance Services - Medically necessary only. $50 copay Air ambulance CYD/30% Coinsurance CYD/30% Coinsurance Ground ambulance CYD/30% Coinsurance CYD/30% Coinsurance Durable Medical Equipment Emergency Care - Includes surgeon and physician costs. Emergency room - The copay is waived when the member is admitted as an inpatient directly from the emergency room. If you receive services from an out-of-network provider, you may be responsible for paying the difference between the billed charges and the plan s allowable amount. The plan s allowable amount is the amount the plan would have paid to an in-network provider. $500 copay $500 copay Urgent care $75 copay Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Hearing Aids - Limited to one every three years. Home Health Care - Includes private-duty nursing. $25 copay Hospice Care Hospice care $50 copay Respite inpatient - Limited to 10 days per 6 months. Respite outpatient - Limited to 10 visits per year. Bereavement services - Limited to 5 visits per year. $50 copay 8XHMF1000SG Page 1

2 Hospital/Outpatient/Ambulatory Services 5 Page 2 HealthFirst/ Inpatient Outpatient surgery Observation Inpatient skilled nursing - Limited to 100 days per calendar year; in-network and out-of-network combined. Acute rehabilitation - Limited to 60 day per calendar year: in-network and out-of-network combined. Infertility Treatment Services Office visit evaluation - Please refer to the applicable surgical procedure copay and/or coinsurance amount for any surgical infertility procedures performed. Infusion Therapy Performed and billed by a physician s office or free-standing outpatient facility $50 copay Performed and billed by a hospital outpatient facility * In-network Specialty drugs incur Kidney Dialysis Services - Covered to the extent not covered by Medicare. Laboratory and Pathology Services Laboratory Pathology Mastectomy Reconstructive Services Inpatient surgery Outpatient surgery Maternity Physician: prenatal care and delivery $200 copay per delivery Delivery room and well-baby hospital care Ancillary maternity charges - including but not limited to fetal non-stress tests and amniocentesis Medical Nutrition Therapy Counseling - Limited to 25 visits per calendar year; in-network and out-of-network combined. Mental Health Services Severe Mental Illness $25 copay $50 copay Inpatient Day treatment program Outpatient Outpatient office visit $25 copay

3 Summary of Benefits Mental Health Services (continued) General Mental Health HealthFirst/ Outpatient office visit $25 copay Alcohol and Drug Abuse Services Inpatient withdrawal Inpatient rehabilitation Outpatient rehabilitation/day treatment Outpatient office visit $25 copay Morbid Obesity - Includes inpatient or outpatient services. One procedure per lifetime. Nutritional Supplements - Enteral Therapy and Parenteral Nutrition. Maximum 120 days supply for special food products. Organ Transplants Covered under HMO Only Ostomy Supplies Pediatric Dental - Pediatric Dental Coverage up to Age 19 In-Network Out-of-Network Diagnostic and Preventive Services - Not subject to the Deductible No Charge 30% Coinsurance Basic Restorative Procedures - Subject to the Deductible 20% Coinsurance 50% Coinsurance Major Restorative Procedures - Subject to the Deductible 50% Coinsurance 80% Coinsurance Orthodontia 3 - Subject to the Deductible 50% Coinsurance 80% Coinsurance Preventive Services 6 - For a complete list of covered services, visit Colorectal cancer screening, colonoscopy, sigmoidoscopy, or fecal occult blood test Mammograms - baseline and annual Pap and pelvic exams Periodic health assessments for hearing and vision for ages 19 and under BRCA genetic counseling and testing services Prenatal well visits Prostate screenings Well baby and child visits, immunizations/vaccinations for children through age 17 Preventive sterilization Prosthetics and Orthotics Prosthetics and orthotics - Foot orthotics limited to one pair per member per calendar year; in-network and out-ofnetwork combined Dental/Oral Orthotic Appliances, TMJ and/or Sleep Apnea Limited to one appliance per member per calendar year. Page 3

4 Radiation Oncology Therapy Page 4 HealthFirst/ Specialist office visit $50 copay Hospital outpatient therapy facility fee Radiology and Diagnostic Services 7 Routine X-ray and Routine Diagnostic Tests Performed and billed by a physician s office or freestanding outpatient facility $60 copay Performed in and billed by a hospital outpatient facility $120 copay Imaging and Complex Diagnostic Tests Performed and billed by a physician s office or freestanding outpatient facility CYD/$225 Performed and billed by a hospital outpatient facility CYD/$500 Spinal Manipulation - Includes all covered services related to the spinal manipulation. Up to 26 Visits per year. Temporomandibular Joint Dysfunction $50 copay TMJ surgery - inpatient hospital TMJ non-surgical outpatient office visit $50 copay Therapies Physical, occupational and speech - Limited to 60 visits per condition per member per calendar year. Habilitative - Limited to 60 visits per condition per member per calendar year. Rehabilitative - Limited to 60 visits per condition per member per calendar year. Autism spectrum disorders - Up to 750 hours per member per calendar year Vision - Pediatric - Coverage up to age 19 Eye exam - Limited to one routine eye exam per child per year. Low-vision exam - Limited to one routine eye exam per child per year. $50 copay $50 copay $50 copay CYD/50% coinsurance CYD/50% coinsurance Glasses - Limited to one pair of basic frames and lenses. No Charge CYD/50% coinsurance Post-cataract services - Limited to one pair of basic frames and lenses. $100 copay CYD/50% coinsurance

5 Prescription Coverage In-network Pharmacy FDA-approved formulary preventive medications, including female oral contraceptives PPO In-Network PPO $0 copay Generic $20 copay Preferred brand $40 copay Non-preferred brand $65 copay Specialty drugs PharmacyPlus PharmacyPlus generic $15 copay Not applicable PharmacyPlus brand $35 copay Not applicable Members have the option to fill certain available prescriptions at PharmacyPlus locations for a discounted copay amount. For a complete list of PharmacyPlus locations, please refer to the provider directory. Provider directories can be found online at. Diabetic supplies obtainable from a pharmacy (including: needles, syringes, test strips, lancets and alcohol swabs) available at retail or mail order. This disclosure statement provides only a brief description of some important features and limitations of your policy. The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the EOC once you are enrolled. While in northern Nevada, members receive in-network covered benefits from any HMO provider. Outside Nevada, members receive in-network covered benefits from any Prominence First Health provider. Other than Emergency, no coverage is available in southern Nevada. Members are only eligible to receive out-of-network covered benefits from out-of-state, non-first Health providers. To access the customized Prominence Health Plan First Health provider network, members must visit. 1. Out-of-network - Members who obtain covered benefits from non-plan providers will be responsible for all charges in excess of the eligible medical expense (EME) charges and you could be responsible for all expenses over and above the EME. Those charges in excess of the EME will not be applied to the out-of-pocket maximum. EME services means the maximum amount the plan will pay for a covered service. 2. Deductible - a set amount of covered charges occurring each calendar year which must be paid by the member before benefits are payable under this plan. Copays do not count towards the deductible. 3. Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for nonemergency conditions cannot be used to satisfy the out-of-pocket maximum. 4. Members may be required to obtain a primary care practitioner (PCP) referral to see a specialist. 5. Hospital admissions and certain other services must be prior authorized by HealthFirst Utilization Management Department or you may be subject to financial penalty. 6. Some services listed may be billed as diagnostic procedures, not preventive/screening procedures, which could require a member to pay the share of cost as listed under Radiology and Diagnostic Services. Diagnostic procedures are usually conducted when a member has already been diagnosed with an illness or disease, or a member is receiving follow-up treatment for an existing medical condition. In addition, a member share of cost might be incurred if additional procedures that are not listed on the Preventive Services list are conducted concurrently to the preventive service. Page 5

6 7. Some invasive diagnostic procedures are treated as outpatient hospital visits. Establishing a Primary Care Practitioner (PCP) As a Prominence Health Plan member, you can choose from a comprehensive network of providers and services, from primary care practitioners (PCP), specialists, urgent care clinics, imaging centers, laboratories and more. We strongly encourage you to establish a relationship with a PCP, who can help manage your care and ensure timely receipt of recommended preventive care and other series that may be appropriate. It is always a good idea to check with your PCP before seeking care from a specialist. Your PCP can help you determine if specialty care (i.e., cardiology, gastroenterology, neurology, etc.) is needed. Access to Pediatricians For children, you may designate a pediatrician as the primary care practitioner (PCP). Access to OB/GYN Physicians You do not need prior authorization from or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Customer Service at and Rescissions will not rescind coverage once a member is enrolled unless the individual (or a person seeking coverage on behalf of the individual) performs an intentional act, practice or omission that constitutes fraud, or unless the individual makes an intentional material misrepresentation of fact, as prohibited by the terms of the Evidence of Coverage. Prominence HealthFirst will provide at least 30 days advance written notice to each participant who would be affected before coverage will be rescinded. Emergency Services are provided as follows: a. Without prior authorization requirement, even for out-of-network services; b. Without regard to whether the provider of the services is in-network; c. If the services are out-of-network, without any administrative requirements or coverage limitations that are more restrictive than those imposed on in-network services; and d. Without regard to any other term or condition of the coverage other than (1) The exclusion of or coordination of benefits; (2) An affiliation or waiting period permitted under ERISA, the PHSA, or the Internal Revenue Code or (3) Applicable cost sharing. Language Translation Services If you or someone you are assisting has questions about your health benefits or other information related to your plan coverage, you have the right to receive help and information in a language other than English at no cost. Please call Prominence Health Plan Customer Service at the phone number on the back of your member ID card and they can assist you with access to language translation services. You can also contact Customer Service to ask for the translation of written benefit materials. TTY/TDD services are available by dialing Notice of Privacy Practices Member privacy and security are important to Prominence Health Plan. For comprehensive information about how we protect your personal health information (PHI) and how it may be disclosed, refer to the Evidence of Coverage (EOC). You can access the EOC online at or call Customer Service and a copy can be mailed to you. Page 6

HMO Beyond %_RX 10/30/50

HMO Beyond %_RX 10/30/50 HMO Beyond 3030 100%_RX 10/30/50 Summary of Benefits and CoverageWhat this plan Covers & What it Costs: This is only a summary. If you want more detail about your coverage and costs, you can get the complete

More information

$250 per member. All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum.

$250 per member. All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum. PLAN FEATURES Network Managed Choice POS (Open Access) OUT-OF- Not Applicable Primary Care Physician Selection Deductible (per calendar year) Not Applicable $250 per member Not Applicable $250 per member

More information

Traditional Choice (Indemnity) (08/12)

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

More information

Schedule of Benefits (GR-9N-S DE)

Schedule of Benefits (GR-9N-S DE) Schedule of Benefits (GR-9N-S-01-001-01 DE) Plan Sponsor: The Church of Jesus Christ of Latter-Day Saints-Senior Missionaries Group Policy Number: 840232 Issue Date: June 3, 2013 Effective Date: August

More information

NETWORK CARE. $4,500 Individual. (2-member maximum)

NETWORK CARE. $4,500 Individual. (2-member maximum) PLAN FEATURES Network Open Choice PPO Primary Care Physician Selection Deductible (per calendar year) Not Applicable $750 per member Not Applicable $750 per member (2-member maximum) (2-member maximum)

More information

NETWORK CARE Managed Choice POS (Open Access)

NETWORK CARE Managed Choice POS (Open Access) PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Managed Choice POS (Open Access) Unless otherwise indicated, the Deductible must be met prior to benefits being payable.

More information

$7,000 Individual $14,000 Family

$7,000 Individual $14,000 Family PLAN DESIGN AND BENEFITS - CA Gold AVN HMO 20 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable Deductible

More information

Covered 100%; deductible waived 40%; after deductible

Covered 100%; deductible waived 40%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family All covered expenses accumulate simultaneously toward both the preferred

More information

All covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.

All covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum. PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Deductible (per calendar year) Not Applicable $500 per member Not Applicable $500 per member (2-member maximum) (2-member

More information

NETWORK CARE. $4,500 (2-member maximum)

NETWORK CARE. $4,500 (2-member maximum) PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $4,500 (2-member maximum) Unless otherwise indicated, the Deductible

More information

NETWORK CARE. $250 per member (2-member maximum)

NETWORK CARE. $250 per member (2-member maximum) PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the

More information

Your Plan: 2018 HMO Plan (2940) Your Network: California Care HMO

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

More information

Medical Schedule of Benefits (Effective January 01, December 31, 2017) Johns Hopkins University Employees and Eligible Dependents

Medical Schedule of Benefits (Effective January 01, December 31, 2017) Johns Hopkins University Employees and Eligible Dependents Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $250 $500 Family $750 $1500 Individual $2000 $4000 Family $6000 $12000 Unlimited Acupuncture

More information

Medical Schedule of Benefits (Effective January 01, 2016) Johns Hopkins Bayview Medical Center Non-Union and Union Employees and Eligible Dependents

Medical Schedule of Benefits (Effective January 01, 2016) Johns Hopkins Bayview Medical Center Non-Union and Union Employees and Eligible Dependents Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Hopkins Preferred Network Provider Individual $100 $750 $0 Family $200 $1500 $0 Individual $2000

More information

In-network: $5,000 single / $10,000 family per calendar year. Out-of-network: $10,000 per insured per

In-network: $5,000 single / $10,000 family per calendar year. Out-of-network: $10,000 per insured per Regence BlueShield: Regence Direct Bronze HSA Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible

More information

Covered 100%; deductible waived 30%; after deductible

Covered 100%; deductible waived 30%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $500 Individual $1,000 Family $1,000 Family All covered expenses accumulate separately toward the preferred or non-preferred

More information

Blue Cross Silver, a Multi-State Plan 87

Blue Cross Silver, a Multi-State Plan 87 Blue Cross Silver, a Multi-State Plan 87 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

More information

Covered 100%; deductible waived 50%; after deductible

Covered 100%; deductible waived 50%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per plan year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the in-network or out-of-network

More information

Simply Blue SM PPO Plan 500 Benefits-at-a-Glance

Simply Blue SM PPO Plan 500 Benefits-at-a-Glance Simply Blue SM PPO Plan 500 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions

More information

Covered 100%; deductible waived 50%; after deductible. Covered 100%; deductible waived 50%; after deductible

Covered 100%; deductible waived 50%; after deductible. Covered 100%; deductible waived 50%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,500 Individual $4,500 Individual $3,000 Family $9,000 Family All covered expenses accumulate simultaneously toward both the preferred

More information

Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3

Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3 Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3 Attachment A Benefit Schedule This Plan includes a 12-month waiting period for maternity coverage. Lifetime Maximum Benefit: The combined

More information

Anthem Blue Cross Your Plan: USC HMO Plan (Two Tiered Network) Your Network: California Care HMO

Anthem Blue Cross Your Plan: USC HMO Plan (Two Tiered Network) Your Network: California Care HMO Anthem Blue Cross Your Plan: USC HMO Plan (Two Tiered Network) Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.

More information

Covered 100%; deductible waived 50%; after deductible

Covered 100%; deductible waived 50%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per plan year) $2,250 Individual $6,850 Individual $4,500 Family $13,700 Family All covered expenses accumulate separately toward the preferred or non-preferred

More information

Blue Cross Select Silver 94 Blue Cross Preferred Silver 94

Blue Cross Select Silver 94 Blue Cross Preferred Silver 94 Blue Cross Select Silver 94 Blue Cross Preferred Silver 94 An individual HMO health plan from Blue Care Network of Michigan. Blue Cross Select You may choose from a select network of quality primary care

More information

2016 Summary of Benefits. Classic Rx (HMO)

2016 Summary of Benefits. Classic Rx (HMO) 2016 Summary of s Classic Rx (HMO) Summary Of s January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list

More information

For: Choice POS II - Clerical & Technical and Service & Maintenance Employees Choice POS II (Base Rx) Plan

For: Choice POS II - Clerical & Technical and Service & Maintenance Employees Choice POS II (Base Rx) Plan Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: June 23, 2016 Effective Date: January 1, 2016 Schedule: 2A Booklet Base: 2 For: Choice POS II - Clerical & Technical and Service &

More information

CA HMO Deductible $1,500 70%

CA HMO Deductible $1,500 70% Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists

More information

[Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan]

[Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan] [Plan Information] [Health Plan:] [Primary Member:] [Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]

More information

SCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN Enhanced Access HMO Applies to Oakland, Johnstown, and Titusville campuses

SCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN Enhanced Access HMO Applies to Oakland, Johnstown, and Titusville campuses SCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN Enhanced Access HMO Applies to Oakland, Johnstown, and Titusville campuses This document is called a Schedule of Benefits. It is part of your Certificate

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Health Savings Account Open Access Plus

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Health Savings Account Open Access Plus SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. RADCO Health Savings Account Open Access Plus General Services In-Network Out-of-Network Physician office visit Primary Care Physician (PCP) Physician

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $500 None Family $1,500 All covered expenses accumulate separately toward the non-preferred Deductible. Unless otherwise

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1 General Services In-Network Out-of-Network Physician office visit Primary Care Physician (PCP) Physician Office Visit

More information

Lourdes Health System Proposed Effective Date: Aetna Helathfund Aetna Choice POS ll - ASC Salary Band: Less than $21,000 to $41,999

Lourdes Health System Proposed Effective Date: Aetna Helathfund Aetna Choice POS ll - ASC Salary Band: Less than $21,000 to $41,999 PROVIDED BY LIFE INSURANCE COMPANY FUND FEATURES HealthFund Amount $750 Employee $1,500 Employee + Spouse $1,500 Employee + Child(ren) $1,500 Family Amount contributed to the Fund by the employer Fund

More information

SCHEDULE OF BENEFITS UPMC HEALTH PLAN PANTHER PREMIER PPO

SCHEDULE OF BENEFITS UPMC HEALTH PLAN PANTHER PREMIER PPO SCHEDULE OF BENEFITS UPMC HEALTH PLAN PANTHER PREMIER PPO This document is called a Schedule of Benefits. It is part of your Certificate of Coverage or your Summary Plan Description. Your Schedule of Benefits

More information

Balance 3 up to Allowed Amount 4 after BCBSF pays up to $50. $0 CYD % Coinsurance 6

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

More information

Plan changes are in red In-Network 2015 Out-of-Network

Plan changes are in red In-Network 2015 Out-of-Network General Information Lifetime Maximum Benefit Unlimited Unlimited Annual Maximum Benefit Unlimited Unlimited Coinsurance Percentage 80.00% 50.00% Precertification Requirements Precertification Penalty Covered

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co.

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. SUMMARY OF BENEFITS Ohio Associated Enterprises Health Savings Account Open Access Plus www.mycigna.com Member Services: (866) 494-2111 Cigna Health and Life Insurance Co. General Services In-Network Out-of-Network

More information

Your Plan: Anthem Silver Blue Access PPO 2000/50%/6350 Your Network: Blue Access

Your Plan: Anthem Silver Blue Access PPO 2000/50%/6350 Your Network: Blue Access Your Plan: Anthem Silver Blue Access PPO 2000/50%/6350 Your Network: Blue Access This summary of benefits is a brief outline of coverage, designed to help y ou with the selection process. This summary

More information

Blue Shield 65 Plus (HMO) summary of benefits

Blue Shield 65 Plus (HMO) summary of benefits Blue Shield 65 Plus (HMO) summary of benefits Group Medicare Advantage-Prescription Drug Plan for CalPERS retirees January 1, 2015 to December 31, 2015 Blue Shield of California is a HMO plan with a Medicare

More information

Aetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Individual Deductible* $3,500 $5,000. Family Deductible* $7,000 $10,000

Aetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Individual Deductible* $3,500 $5,000. Family Deductible* $7,000 $10,000 Schedule of Benefits Employer: County of El Paso MSA: 866233 Effective Date: January 1, 2017 Schedule: 1C Booklet Base: 1 For: Aetna Choice POS II Consumer Driven Health Plan (CDHP) Aetna Choice POS II

More information

Your Benefit Summary Providence Oregon Standard Silver Plan

Your Benefit Summary Providence Oregon Standard Silver Plan Your Benefit Summary Providence Oregon Standard Silver Plan Providence Signature Network In-Network Out-of-Network Individual Calendar Year Deductible (family amount is 2 times individual) $2,500 $5,000

More information

Covered 100%; deductible waived 40%; after deductible

Covered 100%; deductible waived 40%; after deductible PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $300 Individual $300 Individual $900 Family $900 Family All covered expenses accumulate separately toward the preferred or non-preferred

More information

CDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO)

CDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO) Introduction to the Summary of Benefits Report for CDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO) January 1, 2015 December 31, 2015 CAPITAL REGION OF NEW YORK STATE

More information

Choice 750 Gold 49831WA

Choice 750 Gold 49831WA Choice 750 Gold Choice 750 Gold 49831WA1860004 INTRODUCTION Welcome Thank you for choosing Premera Blue Cross (Premera) for your healthcare coverage. This benefit booklet tells you about your plan benefits

More information

Anthem Blue Cross of California Your Plan: Anthem Gold HMO 40/20%/6500 Your Network: California Care HMO

Anthem Blue Cross of California Your Plan: Anthem Gold HMO 40/20%/6500 Your Network: California Care HMO Anthem Blue Cross of California Your Plan: Anthem Gold HMO 40/20%/6500 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection

More information

PLAN DESIGN AND BENEFITS Standard PPO Plan

PLAN DESIGN AND BENEFITS Standard PPO Plan North Carolina PPO (Mandated 1 Life Plan) PLAN DESIGN AND BENEFITS Standard PPO Plan PLAN FEATURES PARTICIPATING Deductible (per plan year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family

More information

Your Plan: 2018 Advantage PPO Plan (1VYX) Medical benefits only plan for Retirees with Medicare A&B Your Network: Prudent Buyer PPO

Your Plan: 2018 Advantage PPO Plan (1VYX) Medical benefits only plan for Retirees with Medicare A&B Your Network: Prudent Buyer PPO Anthem Blue Cross ACWA JPIA C00361 Your Plan: 2018 Advantage PPO Plan (1VYX) Medical benefits only plan for Retirees with Medicare A&B Your Network: Prudent Buyer PPO This summary of benefits is a brief

More information

90% after deductible. Unlimited except where otherwise indicated. Primary Care Physician Selection. Unlimited except where otherwise indicated.

90% after deductible. Unlimited except where otherwise indicated. Primary Care Physician Selection. Unlimited except where otherwise indicated. PLAN FEATURES Deductible (per calendar year) $150 Individual $575 Individual $300 Family $1,725 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost

More information

California Natural Products: EPO Option Coverage Period: 01/01/ /31/2017

California Natural Products: EPO Option Coverage Period: 01/01/ /31/2017 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.deltahealthsystems.com or by calling 1-209-858-2525 Ext

More information

PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY

PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY AN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $300 Individual $800 Individual $900 Family $2,400 Family All covered expenses accumulate toward the preferred or non-preferred Deductible. Unless otherwise

More information

Summary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT

Summary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT Summary of Benefits for Available in Hartford county, CT Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal.

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED FUND FEATURES HealthFund Amount $500 Employee $1,000 Employee + 1 $1,500 Employee + 2 $2,000 Employee + 3 or more Amount contributed to the Fund by the employer Fund amount reflected is on a per calendar

More information

In-Network Deductible: $3,000 per Member or $6,000 per family per calendar year.

In-Network Deductible: $3,000 per Member or $6,000 per family per calendar year. GL, 07/07 Schedule of Benefits Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. Member Cost Sharing Summary Cost Sharing Your Plan has the following Member

More information

Your Plan: 2018 Classic PPO Plan (1122 and ZOJZ) Your Network: Prudent Buyer PPO

Your Plan: 2018 Classic PPO Plan (1122 and ZOJZ) Your Network: Prudent Buyer PPO Anthem Blue Cross Your Plan: 2018 Classic PPO Plan (1122 and ZOJZ) Your : Prudent Buyer PPO ACWA JPIA C00361 This summary of benefits is a brief outline of coverage, designed to help you with the selection

More information

SUBLUE AND SUORANGE: 2018 SCHEDULE OF BENEFITS -EMPLOYEE COST SHARING

SUBLUE AND SUORANGE: 2018 SCHEDULE OF BENEFITS -EMPLOYEE COST SHARING Cost Sharing Definitions Annual Deductible 1 (amounts are not cumulative across levels) $100 per individual with a maximum of $250 for a family $300 per individual with a maximum of $1,000 for a family

More information

Traditional PPO Plan (Modified) Benefits-at-a-Glance Trinity Health

Traditional PPO Plan (Modified) Benefits-at-a-Glance Trinity Health Traditional PPO Plan (Modified) Benefits-at-a-Glance Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar year $250 per member $500 per family Copays Fixed Dollar

More information

Schedule of Benefits Phoenix Health Plans, Inc.

Schedule of Benefits Phoenix Health Plans, Inc. Your Policy gives You important information about Your health care benefits. It includes information such as Pre-Authorization requirements. This Schedule of Benefits is issued to You with Your Policy.

More information

What Your Plan Covers and How Benefits are Paid BENEFIT PLAN. Prepared Exclusively for The McClatchy Company. Aetna Classic Care Plan

What Your Plan Covers and How Benefits are Paid BENEFIT PLAN. Prepared Exclusively for The McClatchy Company. Aetna Classic Care Plan BENEFIT PLAN Prepared Exclusively for The McClatchy Company What Your Plan Covers and How Benefits are Paid Aetna Classic Care Plan 1 Table of Contents Schedule of Benefits... 1 Preface...21 Coverage for

More information

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims. Western Michigan Health Insurance Pool Group Number: 71565 Package Code(s): 016 Section Code(s): 1010, 1110 PPO Select 4, RX1, Hearing Effective Date: 01/01/2018 Benefits-at-a-glance This is intended as

More information

Total Health Care USA, Inc.: Total Saver Complete Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Total Health Care USA, Inc.: Total Saver Complete Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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.thcmi.com or by calling 1-800-826-2862 Important Questions

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? 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.avmed.org/go/state or by calling 1-888-762-8633 Important

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA HEALTH INSURANCE COMPANY - SELF-FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA HEALTH INSURANCE COMPANY - SELF-FUNDED PLAN FEATURES Deductible (per plan year) None Individual None Family Member Coinsurance Covered 100% Applies to all expenses unless otherwise stated. Out-of-pocket limit (per plan year) $6,350 Individual

More information

Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Senior Care Plus: Freedom Rx Select Plan (PPO)).

Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Senior Care Plus: Freedom Rx Select Plan (PPO)). SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).

More information

FRESENIUS TOTAL HEALTH (HMO SNP)

FRESENIUS TOTAL HEALTH (HMO SNP) Summary of Benefits FRESENIUS TOTAL HEALTH (HMO SNP) (a Medicare Advantage Health Maintenance Organization (HMO) offered by FRESENIUS HEALTH PLANS OF NORTH CAROLINA, INC. with a Medicare contract) Available

More information

MEDICAL SCHEDULE OF BENEFITS HDHP $4,000 PLAN

MEDICAL SCHEDULE OF BENEFITS HDHP $4,000 PLAN MEDICAL SCHEDULE OF BENEFITS HDHP $4,000 PLAN HDHP 4000 LIFETIME MAXIMUM BENEFIT CALENDAR YEAR MAXIMUM BENEFIT Unlimited Unlimited CALENDAR YEAR DEDUCTIBLE (combined with Prescription Drug Card Deductible)

More information

Medical Schedule of Benefits (Effective July 01, June 30, 2018) Johns Hopkins Student Health Program

Medical Schedule of Benefits (Effective July 01, June 30, 2018) Johns Hopkins Student Health Program Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $150 $150 Family $450 $450 Individual $3000 $3000 Family $9000 $9000 Unlimited Acupuncture

More information

SUMMARY OF BENEFITS Fisk University Open Access Plus -BUY-UP PLAN Effective 10/1/2015 Customer Service:

SUMMARY OF BENEFITS Fisk University Open Access Plus -BUY-UP PLAN Effective 10/1/2015  Customer Service: SUMMARY OF BENEFITS Fisk University Open Access Plus -BUY-UP PLAN Effective www.mycigna.com Customer Service: 866-494-2111 Cigna Health and Life Insurance Co. General Services In-Network Out-of-Network

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $250 Individual $500 Individual $500 Family $1,000 Family All covered expenses accumulate simultaneously toward both the preferred

More information

benefits Summary of BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida

benefits Summary of BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida 2016 Summary of benefits BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida Florida Blue is a trade name of Blue Cross and Blue Shield of Florida Inc., an Independent

More information

SUMMARY OF BENEFITS. Alliance Behavioral Healthcare Open Access Plus Plan Effective 7/1/12. Cigna Health and Life Insurance Co.

SUMMARY OF BENEFITS. Alliance Behavioral Healthcare Open Access Plus Plan Effective 7/1/12. Cigna Health and Life Insurance Co. SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Alliance Behavioral Healthcare Effective 7/1/12 Network: GWH/CIGNA Open Access Plus CIGNA has multiple networks. Your plan is paired with the GWH-CIGNA

More information

You have choices about how to get your Medicare benefits

You have choices about how to get your Medicare benefits SECTION 1 Introduction to the Summary of Soundpath Health Charter + Rx (HMO), Soundpath Health Sound + Rx (HMO), Soundpath Health Peak + Rx (HMO) Summary of January 1, 2016 - December 31, 2016 This booklet

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the preferred or

More information

PLAN DESIGN AND BENEFITS - Choice POS % - 08 PARTICIPATING PROVIDERS. $1,500 Individual $4,500 Family

PLAN DESIGN AND BENEFITS - Choice POS % - 08 PARTICIPATING PROVIDERS. $1,500 Individual $4,500 Family Aetna Health Inc Texas Small Group Open Access Plan Effective Date: 11/01/2008 PLAN FEATURES Deductible (per calendar year) PARTICIPATING $1,500 Individual $4,500 Family $3,000 Individual $9,000 Family

More information

2016 Forever Blue Medicare PPO

2016 Forever Blue Medicare PPO 2016 Forever Blue Medicare PPO H5526 Summary of Benefits FOREVER BLUE MEDICARE PPO VALUE (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare

More information

and cardiac diagnostic procedures utilizing nuclear medicine) Bariatric surgery Not Covered Not Covered

and cardiac diagnostic procedures utilizing nuclear medicine) Bariatric surgery Not Covered Not Covered An independent member of the Blue Shield Association Wesco Aircraft ASO PPO Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective:

More information

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 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

More information

What is the overall deductible?

What is the overall deductible? Molina Healthcare of California: Molina Silver 70 HMO Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan

More information

NATIONAL HEALTH & WELFARE FUND PLAN C

NATIONAL HEALTH & WELFARE FUND PLAN C H E A LT H A N N U I T Y I O N P E N S I O N V A C AT NATIONAL HEALTH & WELFARE FUND PLAN C BENEFITS AT A GLANCE Introduction The IATSE National Health & Welfare Fund was set up to provide health care

More information

Schedule of Benefits

Schedule of Benefits Schedule of Benefits NHP Prime HMO plan for GIC members Exclusively for members of the Group Insurance Commission health plan meets Minimum Creditable Coverage standards and will satisfy the individual

More information

Regence BlueShield: Innova 2500 Coverage Period: 11/01/ /31/2017

Regence BlueShield: Innova 2500 Coverage Period: 11/01/ /31/2017 Regence BlueShield: Innova 2500 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 11/01/2016 10/31/2017 Coverage for: Individual and Eligible Family Plan Type: PPO

More information

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct HMO Plus (HMO)

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct HMO Plus (HMO) FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct HMO Plus (HMO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties P age 1 SECTION I - INTRODUCTION TO SUMMARY

More information

Important Questions Answers Why this Matters:

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 by calling 1-585-343-0055 ext. 6415. Important Questions Answers

More information

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED

PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $150 Individual $600 Individual $300 Family $1,200 Family All covered expenses accumulate separately toward the preferred or non-preferred

More information

Blue Precision Silver HMO 106 Blue Precision HMO SM

Blue Precision Silver HMO 106 Blue Precision HMO SM Blue Precision Silver HMO 106 Blue Precision HMO SM OUTLINE OF COVERAGE 1. READ YOUR POLICY CAREFULLY. This outline of coverage provides a brief description of the important features of your Policy. This

More information

OUTLINE OF COVERAGE. Blue Choice PPO Bronze 005

OUTLINE OF COVERAGE. Blue Choice PPO Bronze 005 OUTLINE OF COVERAGE 1. READ YOUR POLICY CAREFULLY. This outline of coverage provides a brief description of the important features of your Policy. This is not the insurance contract, and only the actual

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? 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.myscrippshealthplan.com or by calling 1-877-552-7247.

More information

Important Questions Answers Why this Matters: Member $3,000/$4,500/$8,000 (Option 1/Option 2/Option 3) What is the overall

Important Questions Answers Why this Matters: Member $3,000/$4,500/$8,000 (Option 1/Option 2/Option 3) What is the overall 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.rmhp.org or by calling 1-800-346-4643. Important Questions

More information

Summary of Benefits. BlueMedicare SM HMO A Medicare Advantage HMO Plan. Miami-Dade County. Y0011_ CMS Accepted

Summary of Benefits. BlueMedicare SM HMO A Medicare Advantage HMO Plan. Miami-Dade County. Y0011_ CMS Accepted 2015 Summary of Benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Miami-Dade County Y0011_32459 0814 CMS Accepted (HMO) Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives

More information

Nationwide Life Ins. Co.: SUNY Maritime College Coverage Period: 8/11/13 8/10/14

Nationwide Life Ins. Co.: SUNY Maritime College Coverage Period: 8/11/13 8/10/14 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.chpstudent.com or by calling 1-800-633-7867. Important

More information

Companion Life Insurance Company: New England Culinary Institute Coverage Period: 7/1/14-7/1/15

Companion Life Insurance Company: New England Culinary Institute Coverage Period: 7/1/14-7/1/15 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.chpstudent.com or by calling 1-800-633-7867. Important

More information

PPO $500 Deductible Plan: Xavier University Summary of Benefits and Coverage: What this Plan Covers & What it Costs

PPO $500 Deductible Plan: Xavier University Summary of Benefits and Coverage: What this Plan Covers & What it Costs 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 by contacting Lindsay Klinzman at klinzmanl@xavier.edu or by

More information

Anthem Blue Cross of California Your Plan: Anthem Gold PPO 500/20%/6500 Your Network: Prudent Buyer PPO

Anthem Blue Cross of California Your Plan: Anthem Gold PPO 500/20%/6500 Your Network: Prudent Buyer PPO Anthem Blue Cross of California Your Plan: Anthem Gold PPO 500/20%/6500 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection

More information

$ 600 individual / $ 1,200 family Does not apply to prescription drugs or exercise facility reimbursements. $ 4,000 individual / $ 8,000 family

$ 600 individual / $ 1,200 family Does not apply to prescription drugs or exercise facility reimbursements. $ 4,000 individual / $ 8,000 family 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.metroplus.org or by calling 1-855-809-4073. Important

More information

2016 Senior Blue HMO H3384. Summary of Benefits

2016 Senior Blue HMO H3384. Summary of Benefits 2016 Senior Blue HMO H3384 Summary of Benefits BLUECROSS BLUESHIELD SENIOR BLUE HMO 601 (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare

More information

Active and Retiree Medical Benefit Summary Plan Description And Plan Document /

Active and Retiree Medical Benefit Summary Plan Description And Plan Document / Active and Retiree Medical Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309 Revised 01-01-2018 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 1 PLAN INFORMATION...

More information

ARUP Laboratories, Inc. EPO Medical 750 Plan Coverage Period: 01/01/ /31/2017

ARUP Laboratories, Inc. EPO Medical 750 Plan Coverage Period: 01/01/ /31/2017 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.uhealthplan.utah.edu/aruplabs/ or by calling 1-888-271-5870.

More information

Changes in some state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage.

Changes in some state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. BlueCare Direct Silver SM 212 with Advocate BlueCare Direct SM OUTLINE OF COVERAGE 1. READ YOUR POLICY CAREFULLY. This outline of coverage provides a brief description of the important features of your

More information

Your Plan: Anthem HealthKeepers Silver OAPOS 3500/0%/3500 w/hsa Your Network: HealthKeepers

Your Plan: Anthem HealthKeepers Silver OAPOS 3500/0%/3500 w/hsa Your Network: HealthKeepers Your Plan: Anthem HealthKeepers Silver OAPOS 3500/0%/3500 w/hsa Your Network: HealthKeepers This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This

More information

EnhancedBlue SM Gold 1000 PPO

EnhancedBlue SM Gold 1000 PPO EnhancedBlue SM Gold 1000 PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 12/31/2016 Coverage for: Single & Family Plan Type: PPO This is only a

More information

Important Questions Answers Why this Matters:

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.studentplanscenter.com or by calling 1-800-756-3702.

More information