Medical Schedule of Benefits (Effective January 01, December 31, 2017) Johns Hopkins University Employees and Eligible Dependents
|
|
|
- Florence Franklin
- 6 years ago
- Views:
Transcription
1 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 Allergy Tests & Procedures Medically necessary services for anesthesia, pain control, and therapeutic purposes 80% of allowed amount (15 visits annual maximum for all networks combined); deductible applies 70% of R&C; deductible applies (15 visits annual maximum for all networks combined )deductible applies Allergy tests Desensitization materials and serum Ambulance Transportation Medically necessary transport Biofeedback Biofeedback 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Chemo & Radiation Therapy Chiropractic Care Physician visit Materials and treatment Chiropractor restricted to initial exam, x- rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) Refer to Therapy section Refer to Therapy section Dialysis Medically necessary services 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Durable Medical Equipment Breast pumps (standard) and related supplies 100% of allowed amount; deductible waived 70% of R&C; deductible applies Contraceptive devices 100% of allowed amount; deductible waived 70% of R&C; deductible applies Custom DME, including custom wheelchairs 80% of allowed amount; deductible applies (pre-authorization 70 % of R&C; deductible applies (pre-authorization Custom-molded orthotics 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Insulin pumps, Continuous Glucose Monitor and related supplies Hearing aids Non-custom medical equipment and supplies 80% of allowed amount; deductible applies (for dependent children up to 70% of R&C; deductible applies (for dependent children up to age 26; preauthorization required; all networks combined) replacement aids once every age 26; pre-authorization required; all networks combined) replacement aids once every 36 months 36 months Prosthetic devices 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization E00015, E00151 (*001/*002) Page 1 of 6
2 Emergency Services Home Health Services Emergency care (facility waived if admitted); See Inpatient Facility Care for coverage) waived if admitted; See Inpatient Facility Care for coverage) Emergency care 80% of allowed amount; deductible applies 80% of R&C; deductible applies Medically necessary services 100% of allowed amount; deductible waived (90 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (90 visits per year maximum for all networks combined; pre-authorization Home infusion therapy 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Hospice Care Inpatient and home hospice 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Hospital Care Inpatient care including newborn nursery care; NICU (facility $250 co-pay per admission, then 80% of allowed amount; deductible applies (semi-private, unless private room is medically necessary; pre-authorization $250 co-pay per admission, then 70% of R&C; deductible applies (semiprivate, unless private room is medically necessary; pre-authorization Inpatient care 80% of allowed amount, after deductible 70% after deductible Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care (facility 80% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization 80% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization waived if admitted); see Inpatient Facility Care for coverage 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization waived if admitted); see Inpatient Facility Care for coverage Observation care 80% of allowed amount; deductible applies 80% of R&C; deductible applies Outpatient surgery & ambulatory surgical center (facility Outpatient surgery & ambulatory surgical center 100% of allowed amount; deductible waived (includes freestanding surgical centers) 80% of allowed amount; deductible applies (includes outpatient testing prior to outpatient surgery) 70% of R&C; deductible applies (includes freestanding surgical centers) 70% of R&C; deductible applies (includes outpatient testing prior to outpatient surgery) Hyperbaric Oxygen Therapy Medically necessary services 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Immunizations Infusion Therapy Preventive immunizations for communicable diseases 100% of allowed amount; deductible waived 70% of R&C; deductible waived Travel immunizations 100% of allowed amount; deductible waived 70% of R&C; deductible waived Home infusion therapy 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Outpatient infusion therapy E00015, E00151 (*001/*002) Page 2 of 6
3 Injections Injections Materials and serum Laboratory Laboratory tests including pathology Mental Health & Substance Abuse Services Outpatient mental health care (facility Outpatient mental health care Inpatient mental health care (facility Inpatient mental health care (professional Outpatient substance abuse care (facility Outpatient substance abuse care Inpatient substance abuse care (facility Inpatient substance abuse care $250 co-pay per admission, then 80% of allowed amount; deductible applies (pre-authorization $250 co-pay per admission, then 80% of allowed amount; deductible applies (pre-authorization Intensive outpatient program 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Partial hospital facility services 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Medication management Mental health testing and procedures 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Methadone Treatment Medically necessary outpatient care 80% of allowed amount; deductible waived 70% of R&C; deductible applies Nutritional Counseling Medically necessary services 80% of allowed amount; deductible applies (limited to 2 visits per plan year for all networks combined; additional visits must be pre-authorized) 70% of R&C; deductible applies (limited to 2 visits per plan year for all networks combined; additional visits must be pre-authorized) E00015, E00151 (*001/*002) Page 3 of 6
4 Office Visits for Treatment of Illness or Injury Preventive Services Primary care office visit only (Adult) Primary care office visit (Pediatric: age 19 and under) Primary care office visit only (GYN) Specialty care office visit only (Adult & Pediatric) Treatment and diagnostic services in the office Preventive exam (PCP, GYN and Well Child care) 100% of allowed amount; deductible waived 70% of R&C; deductible waived Diagnostic services for preventive exam 100% of allowed amount; deductible waived 70% of R&C; deductible waived Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. 100% of allowed amount; deductible waived 70% of R&C; deductible waived Routine hearing exams Private Duty Nursing Private Duty Nursing Not Available Not Available Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound E00015, E00151 (*001/*002) Page 4 of 6
5 Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment 80% of allowed amount; deductible applies (maximum lifetime benefit: $100,000; maximum of 6 attempts per live birth for artificial insemination and intrauterine insemination; maximum of 3 attempts per live birth for in vitro fertilization; pre-authorization required for all services) 70% of R&C; deductible applies (maximum lifetime benefit: $100,000; maximum of 6 attempts per live birth for artificial insemination and intrauterine insemination; maximum of 3 attempts per live birth for in vitro fertilization; pre-authorization required for all services) Birthing centers (facility Birthing centers Inpatient maternity care and delivery; $250 co-pay per admission, then 80% of allowed amount; deductible applies newborn nursery care; NICU (facility (pre-authorization Inpatient maternity care and delivery; newborn nursery care; NICU Interruption of pregnancy Female sterilization (professional services for surgery, anesthesia and related pathology) Male sterilization (professional services for surgery, anesthesia and related pathology) 100% of allowed amount; deductible waived 100% of R&C; deductible waived Surgical treatment for morbid obesity 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Primary care office surgical procedures Specialist care office surgical procedures Outpatient surgery (including freestanding surgical centers) (facility Outpatient surgery (including freestanding surgical centers) Inpatient surgery (facility 100% of allowed amount; deductible waived 70% of R&C; deductible applies $250 co-pay per admission, then 100% of allowed amount; deductible waived (pre-authorization Inpatient surgery 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization E00015, E00151 (*001/*002) Page 5 of 6
6 Therapy Urgent Care Center Habilitative services for children under the age of 19 Physical therapy/occupational therapy medically necessary services Speech therapy (non-developmental medically necessary services) 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 80% of allowed amount; deductible applies (45 visits per year combined maximum for all networks) 80% of allowed amount; deductible applies (30 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (45 visits per year combined maximum for all networks) 70% of R&C; deductible applies (30 visits per year maximum for all networks combined; pre-authorization Pulmonary rehabilitation 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Cardiac rehabilitation 80% of allowed amount; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization Vision therapy Not Available Not Available Physician visit $50 co-pay, then 100% of allowed amount, deductible waived $50 co-pay, then 100% of R&C, deductible waived Diagnostic services and treatment 100% of allowed amount; deductible waived 100% of R&C; deductible waived E00015, E00151 (*001/*002) Page 6 of 6
Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) JHH/JHHSC Non-Union and Union Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Preferred Network Provider EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined with EHP Network)
Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) Howard County General Hospital/TCAS Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Affiliated Facility Network (facility charges only) EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined
Standard Option Medical Schedule of Benefits (Effective January 01, 2018) Suburban Hospital Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Suburban Hospital (facility charges only) Individual $400 $750 $0 Family $800 $1500 $0 Individual
Medical PPO Plan Schedule of Benefits (Effective January 01, 2019) Bayview Non-Union and Union Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Individual Family Individual Family Hopkins Preferred Network Provider EHP Network Provider Out of Network Provider $150 (under $50K) / $200
Standard Option Medical Schedule of Benefits (Effective January 01, 2017) Suburban Hospital Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Suburban Hospital (facility charges only) Individual $400 $750 $0 Family $800 $1500 $0 Individual
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
Medical Schedule of Benefits (Effective July 01, June 30, 2019) 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
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
ENROLLMENT APPLICATION
ENROLLMENT APPLICATION HOW TO ENROLL IN EHP Please detach this page and review these instructions before completing the "Enrollment Application". If you have any questions, please contact an HR Service
SCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center
SCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center The following Schedule of Benefits is part of your Certificate of Coverage. It sets forth benefit limits
LOCKHEED MARTIN AERONAUTICS COMPANY MARIETTA 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Calendar Year Out-of- Pocket Maximum Lifetime Maximum Per Individual Physician Office Visits Primary Care
LOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS ACTIVE EMPLOYEE S LM HEALTHWORKS (PPO) SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Employee Only: $650 Employee +1: $1,300 ($650 per person) Employee +2 or more: $2,000 (with no more than $650
PLAN DESIGN AND BENEFITS - IN MANAGED CHOICE POS OPEN ACCESS 90/60/60 $1,000 PREFERRED CARE
PLAN FEATURES NON- Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
SCHEDULE OF BENEFITS UPMC HEALTH PLAN PA CHILD WELFARE RESOURCE PPO
SCHEDULE OF BENEFITS UPMC HEALTH PLAN PA CHILD WELFARE RESOURCE PPO This document is called a Schedule of Benefits. It is part of your Certificate of Coverage or your Summary Plan Description. Your Schedule
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: MSA Contract Number Control Number:: Barnes Group Inc. 397393 842881 Issue Date: February 15, 2017 Effective Date: January 1, 2017 Schedule: 3A Booklet Base: 3 For: Indemnity
North Carolina Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010
PLAN FEATURES [Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for for prescription
Aetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: September 29, 2014 Effective Date: January 1, 2014 Schedule: 8A Booklet Base: 8 For: Aetna Choice POS II - Yale Police Benevolent
Schedule of Benefits. Plan Information. Member Cost Sharing
Schedule of Benefits Panther Gold Plan - Enhanced Access HMO Applies to Bradford, Johnstown and Greensburg campuses only HMO Deductible: $0 / $0 Coinsurance: 0% Total Annual Out-of-Pocket: $1,800 / $3,600
California Small Group MC Aetna Life Insurance Company NETWORK CARE
PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred
Quote Effective: 04/01/ /30/2019 Version Updated: 01/07/2019
Quote Effective: 04/01/2019-06/30/2019 Version Updated: 01/07/2019 Print Package: HIOS ID (Enrollment Code) 78124NY1000265-00 (SON5) Plan Name: Rating Region: Rate Rochester For the Benefits described
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 3A Booklet Base: 3 For: Choice POS II - 1250 Option - Retirees
Anthem Blue Cross Effective: January 1, 2018 Your Plan: University of California UC Care Plan Your Network: UC Select and Anthem Preferred
Anthem Blue Cross Effective: January 1, 2018 Your Plan: University of California UC Care Plan Your Network: UC Select and Anthem Preferred This summary of benefits is a brief outline of coverage, designed
Aetna Select Clerical & Technical and Service & Maintenance Employees. Schedule of Benefits
Aetna Select Clerical & Technical and Service & Maintenance Employees Schedule of Benefits If this is an ERISA plan, you have certain rights under this plan. Please contact your employer for additional
California Small Group MC Aetna Life Insurance Company
PLAN FEATURES Deductible (per calendar year) $5,000 Individual $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This
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
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
For: 80/20 Plan for Retired Employees Over Age 65 and Dependents
Schedule of Benefits Employer: Cornell University ASC: 397366 Issue Date: September 1, 2010 Effective Date: September 1, 2010 Schedule: 11A Booklet Base: 11 For: 80/20 Plan for Retired Employees Over Age
WA Bronze PPO Saver /50 (1/14)
PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services, including member cost sharing
Simply Blue SM PPO Plan $1000 LG Medical Coverage Benefits-at-a-Glance
Simply Blue SM PPO Plan $1000 LG Medical Coverage Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only a general overview of your benefits.
Choice POS II (Legacy) Faculty, Managerial & Professional, Post Doctoral Associates and Post Doctoral Fellows Employees. Schedule of Benefits 1A
Choice POS II (Legacy) Faculty, Managerial & Professional, Post Doctoral Associates and Post Doctoral Fellows Employees Schedule of Benefits If this is an ERISA plan, you have certain rights under this
Adventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018
Adventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018 High Health Plan with Health Savings Account (Health Savings Plan) TIER 1 TIER 2 TIER 3 CALENDAR YEAR
PLAN DESIGN AND BENEFITS - Tx OAMC % 08 PREFERRED CARE
Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 11/01/2008 PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Individual $3,000 3 Individuals per $9,000
Emergency Department: $175 Copayment per visit Coinsurance: 0%
Schedule of Benefits UPMC Small Business Advantage Primary Care Provider: $25 Copayment per visit Gold PPO $1,000 $25/$50 - Premium Network Specialist: $50 Copayment per visit Deductible: $1,000 / $2,000
MEMBER COST SHARE. 20% after deductible
PLAN FEATURES Network Not Applicable Primary Care Physician Selection Not Applicable Deductible (per calendar year) $500 Individual (2-member maximum) Unless otherwise indicated, the Deductible must be
OPERATING ENGINEERS LOCAL324 Community Blue PPO Effective Date: 01/01/2016
OPERATING ENGINEERS LOCAL324 Community Blue PPO 007005154 Effective Date: 01/01/2016 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract.
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
For: Traditional Choice - Over Age 65 Corning Retirees - Comprehensive Medical Only - MAP Plus Option 1
Schedule of Benefits Employer: ASA: Control: The Dow Chemical Company 783135 865282 Issue Date: March 15, 2017 Effective Date: March 1, 2017 Schedule: 120B Booklet Base: 120 For: Traditional Choice - Over
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
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Rider University ASA: 884014 Issue Date: January 2, 2013 Effective Date: January 1, 2013 Schedule: 1E Booklet Base: 1 For: Choice POS II (Aetna Choice POS II) Safety Net
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
Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum $2,000 per individual / $4,000 per family Lifetime Benefit Maximum
An independent member of the Blue Shield Association Access+HMO Per Admit 20-500 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California
IL Small Group MC Open Access Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- MC $1,500 80/50/50 (04/09)
PLAN FEATURES Deductible (per calendar ) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits Panther Basic HSA PPO - Premium Network Deductible: $1,500 / $3,000 Coinsurance: 30% Total Annual Out-of-Pocket: $5,000 / $10,000 Primary Care Provider: 30% after Deductible Specialist:
$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
Aetna Select Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Plan Maximum Out of Pocket Limit excludes precertification penalties.
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: July 25, 2016 Effective Date: January 1, 2016 Schedule: 12D Booklet Base: 12 For: Aetna Select - Security Staff (Outside CT) Electing
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 Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the
Full PPO Savings Two-Tier Embedded Deductible 2250/2700/4500 Effective January 1, 2019
Benefit Modification for Members with Full PPO Savings Two-Tier Embedded Deductible 2250/2700/4500 Effective January 1, 2019 This chart is a summary of specific benefit changes to your plan. For a list
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:
BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
GRPS Simply Blue Option C $500/$1000 deductible, $20, $40, $80 rx Eligible Groups: Support Non Exempt, Exempt/Professional Admin. Western Michigan Health Insurance Pool Group Number: 71565 Package Code(s):
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)
Individual Deductible* $950 $950. Family Deductible* $1,900 $1,900
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 22, 2018 Effective Date: January 1, 2018 Schedule: 3B Booklet Base: 3 For: Choice POS II - $950 Option - Retirees
Other Participating UPMC Facilities Level 2 Benefit Period
Schedule of Benefits Advantage Panther Gold Plan - Enhanced Access HMO Applies to Oakland and Titusville campuses HMO Deductible: $0 / $0 Coinsurance: 0% Total Annual Out-of-Pocket: $1,800 / $3,600 Primary
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.
Simply Blue SM HSA PPO Plan 2000/0% LG Medical Coverage with Prescription Drugs Benefits-at-a-Glance
Simply Blue SM HSA PPO Plan 2000/0% LG Medical Coverage with Prescription Drugs Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only
For more information on your plan, please refer to the final page of this document.
Schedule of Benefits Panther Blue - General Student Health Plan PPO - Premium Network Deductible: $250 / $500 Coinsurance: 10% Total Annual Out-of-Pocket: $4,200 / $8,400 This document is your Schedule
PLAN DESIGN AND BENEFITS MC Open Access Plan 1913
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $1,500 Individual $4,500 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Adobe Systems Incorporated MSA: 660819 Issue Date: January 1, 2018 Effective Date: January 1, 2018 Schedule: 2B Booklet Base: 2 For: Aetna Choice POS II HDHP - HealthSave
Aetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Individual Deductible* $1,000 $2,000. Family Deductible* $2,000 $4,000
Schedule of Benefits Employer: Adobe Systems Incorporated ASC: 660819 Effective Date: January 1, 2012 Schedule: 2B Booklet Base: 1 For: Aetna Choice POS II 80/60 Plan This is an ERISA plan, and you have
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
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
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
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Adobe Systems Incorporated MSA: 660819 Issue Date: January 1, 2018 Effective Date: January 1, 2018 Schedule: 1A Booklet Base: 1 For: Aetna Choice POS II with Health Fund
Blue Cross Silver, a Multi-State Plan 94
Blue Cross Silver, a Multi-State Plan 94 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
Benefits-at-a-Glance for MSU Student Health Plan
Benefits-at-a-Glance for MSU Student Health Plan 2016-2017 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
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
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 &
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
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
Schedule of Benefits Aetna Consumer Directed Health Plan (CDHP) January 1, 2018
Schedule of Benefits Aetna Consumer Directed Health Plan (CDHP) January 1, 2018 This is an ERISA plan, and you have certain rights under this plan. Please contact the Human Resources Benefits Team for
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 2B Booklet Base: 2 For: Choice POS II with Aetna HealthFund -
I. PLAN DESCRIPTIONS. A. POS Point of Service
I. PLAN DESCRIPTIONS A. POS Point of Service The Partnership Plan offers a single point of service plan to provide healthcare services both within and outside a defined network of Providers. No referrals
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
Schedule Of Benefits
Schedule Of Benefits Subject to the exclusions, conditions and limitations of this Plan, a Covered Person is entitled to benefits for the Covered Services described in this Schedule of Benefits during
Summary of Coverage. $6,350 / $12,700 (Includes Deductibles, Copays and Coinsurance Amounts) Preventive Care Covered at 100%
Benefits for 2017-2018 Medical Summary of Coverage Plan Features Blue Care Network HMO HRA IN NETWORK Purchased Deductible * Employee Deductible * $4,000 individual / $8,000 family * $500 individual /
Full PPO Combined Deductible /60 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)
An independent member of the Blue Shield Association Full PPO Combined Deductible 25-250 90/60 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield
Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits Panther Advocate - HealthyU HIA PPO - Premium Network Deductible: $500 / $1,000 Coinsurance: 10% Total Annual Out-of-Pocket: $2,000 / $4,000 Primary Care Provider: 10% after Deductible
SHL Solutions PPO 25/750/80%
SHL Solutions PPO 25/750/80% Attachment A Benefit Schedule Lifetime Maximum Benefit for all Covered Services: Unlimited. Calendar Year Deductible (CYD): Your CYD is $750 of EME per Insured and $1,500 of
Benefits Summary SelectHC IV
Benefits Summary SelectHC IV An Embedded Deductible, High Deductible Health Plan (HDHP) This chart only summarizes covered benefits. Please refer to the Policy for coverage details including exclusions
ST. MARY S HEALTHCARE SYSTEM, INC.-CASE # GA6476 Blue Choice HI PPO Benefit Summary Effective: January 1, 2019
ST. MARY S HEALTHCARE SYSTEM, INC.-CASE # GA6476 Blue Choice HI PPO Benefit Summary Effective: January 1, 2019 All benefits are subject to the calendar year deductible, except those with in-network copayments,
Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider. Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance: 0%
Schedule of Benefits UPMC Business Advantage PPO - Premium Network Primary Care Provider: $20 Copayment per visit Specialist: $20 Copayment per visit Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance:
NETWORK CARE. $3,500 Individual $7,000 Family
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Managed Choice POS (Open Access) OUT-OF- $2,000 Individual $4,000 Family Unless otherwise indicated, the Deductible
MEDICAL SCHEDULE OF BENEFITS COPAY GOLD
LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes medical Deductible, medical Coinsurance, medical Copays
Member Cost Sharing Participating Provider Non-Participating Provider Annual Deductible Individual $250 $750 Family $750 $2,250
Schedule of Benefits UPMC Business Advantage PPO - Premium Network Deductible: $250 / $750 Coinsurance: 0% Total Annual Out-of-Pocket: $6,350 / $12,700 Primary Care Provider: $20 Copayment per visit Specialist:
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
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Apria Healthcare Group, Inc. ASA: 476706 Issue Date: May 7, 2013 Effective Date: January 1, 2013 Schedule: 2A Booklet Base: 2 For: Choice POS II High Deductible Health Plan-Apria
$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
SCHEDULE OF BENEFITS UPMC HEALTH PLAN - POINT PARK UNIVERSITY STUDENT HEALTH PLAN
SCHEDULE OF BENEFITS UPMC HEALTH PLAN - POINT PARK UNIVERSITY STUDENT HEALTH PLAN Covered Services, which may be subject to a Deductible and Coinsurance, are provided during a Benefit Period as outlined
COVENTRY HEALTH AND LIFE INSURANCE COMPANY (Maryland) 2751 Centerville Road, Suite 400 Wilmington, DE
COVENTRY HEALTH AND LIFE INSURANCE COMPANY (Maryland) 2751 Centerville Road, Suite 400 Wilmington, DE 19808-1627 PPO SCHEDULE OF BENEFITS 100/80; $100 Combined Deductible This Schedule is part of Your
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
NETWORK CARE. $1,000 Individual $2,000 Family
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $3,500 Individual $7,000 Family Unless otherwise indicated, the Deductible
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
Group Name. South Seneca School District
Group Name South Seneca School District Excellus BlueCross BlueShield makes finding the information and support you need easier resources, savings, and tools are available online 24/7. Find a doctor or
This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Marist College MSA: 837090 Issue Date: May 5, 2017 Effective Date: January 1, 2017 Schedule: 3A Booklet Base: 3 For: Aetna Choice POS II - $1,000 Deductible Plan This is
Denver Public Schools
2016 Denver Public Schools DHMP $3500 CDHP HighPoint Denver Plus Deductible Individual Family n $3,500 per plan year. n $7,000 per plan year. HighPoint Denver Cofinity Out of An individual will not pay
$4,800 $9,600 Maximum Lifetime Benefit
PPO Schedule of PPO Medical C & A Industries, Inc. Plan Effective Date: January 1, 2019 In-Network Out-of-Network** Benefit Year means a calendar year, which is the period of twelve (12) consecutive months
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): 066, 067 Section Code(s): 3000, 3100, 3300, 3400 PPO - ACA Plan, RX 24 Effective Date: 01/01/2018 Benefits-at-a-glance This is
PLAN DESIGN & BENEFITS
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $250 Individual $500 Individual $500 Family $1,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
Summary of Benefits. Custom PPO Combined Deductible /60. City of Reedley Effective January 1, 2018 PPO Benefit Plan
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Custom PPO Combined Deductible 35-500 80/60 City of Reedley Effective January 1, 2018 PPO Benefit Plan
Effective: July 1, Highlights: A description of the prescription drug coverage is provided separately. Participating Providers 1
High Desert & Inland Trust Custom PPO 3 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: July 1, 2016 THIS MATRIX IS