2018 Summary of Medical Plan Benefits
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- James Gilmore
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1 Deductibles 2018 Summary of Medical Plan Benefits Annual Deductible $1,000 per individual $2,000 per individual $1,500 per Individual $2,500 per individual $2,200 for employee only coverage level** $4,000 for employee only coverage level** Family Deductible $3,000 family $6,000 family Hospital Deductible None $250 per admission* Out of Pocket Maximum $4,500 per $13,500 family $7,500 per $22,500 family $4,500 family None $7,150 per $14,300 family Page 1 $7,500 family $250 per admission* $10,500 per $31,500 family $6,600 for employee & 1 or more family members**(collective ) None $6,550 per individual; $13,100 for employee & 1 or more family members** $12,000 for employee & 1 or more family members** (collective ) None Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited *Separate from annual **Deductibles and out-of-pocket s for the Quality Connect plan are based on 2018 amounts allowed by the IRS. Preventive Care $13,000 per individual; $26,000 for employee & 1 or more family members** Routine Physicals 100%, Immunizations 100%, Well Child Care 100%, Well Baby Care (Newborn to Age 2) 100%, Annual Well Woman Exams 100%, *There is no longer a preventive care.
2 Prescriptions Generic No cost after $0 No cost $0 No cost Generic Preventive Retail 30 day supply $0 No cost Not available $0 No cost Not available $0 No cost Not available ( See List ) Brand name $40 co-pay (30-day supply), $40 co-pay (30-day supply), 30% after * * Non-preferred Brand Specialty High-Cost Drugs Mail Order $60 co-pay (30-day supply), $100 $0 generic and $80/brand name, $120/nonpreferred, $200 specialty up to a 90- day supply, Not available $60 co-pay (30-day supply), $100 $0 generic and $80/brand name, $120/nonpreferred, $200 specialty up to a 90- day supply, Not available * * 20%/generic, 30%/brand name and 50%/nonpreferred brand and specialty after for up to 90-day supply * Not available Generic Preventive Mail Order 90 day supply ( See List ) $0 No cost Not available $0 No cost Not available $0 No cost Not available *Brand name prescriptions will not be covered more than even if the physician requests that the prescription not be filled with a generic equivalent. Walgreens is no longer an In-Network pharmacy/prescription PPIs & allergy medications are not covered by any of the plans. Page 2
3 Office Visits Physician Services $25 co-pay, $45 co-pay, MCNT/USMD $25 co-pay, $35 co-pay, 85/15 after After Hours Specialists $40 co-pay, $60 co-pay, Specialists - CCD $40 co-pay, $50 co-pay, 85/15 after Airrosti $25 co-pay, $45 co-pay, 85/15 after Urgent Care Laboratory X-Rays Outpatient Surgery * * * * * * Allergy Testing & Injections Emergency ** ** ** ** ** ** * Some surgeries are required to be performed on an outpatient basis or benefits will be substantially reduced. ** Non-Emergency care in an Emergency Room may NOT be covered. Please call Cigna or review Cigna s Summary of Benefits. Page 3
4 Mental Health Benefit + Network Out-of-Network Network Out-of-Network Network Out-of-Network Inpatient Services annual s annual s annual s Outpatient Services s s Inpatient Serious Mental Illness annual s Outpatient Serious Mental Illness $25 copay + No yearly plan s annual s $45 copay s annual s s Substance Abuse Treatment Benefit + Network Out-of-Network Network Out-of-Network Network Out-of-Network Inpatient Services ; annual s; ; annual s annual Outpatient Services + No yearly plan s $45 Primary $60 - Specialist s s Page 4
5 Hospital Charges Room & Board (semi-private room) annual s annual s annual s Physician Services Surgeon Services Anesthesiology Nursery Charges Emergency Services Laboratory Services X-Rays Pre-Admission Testing ** annual s annual s annual s annual s ** annual s annual s annual s * ** ** annual s annual s annual s annual s ** annual s annual s annual s * ** ** Outpatient Surgery * * * Ambulance ** ** ** * Some surgeries are required to be performed on an outpatient basis or benefits will be substantially reduced. ** Life threatening situations. Non-Emergency care in an ER may NOT be covered. Please call Cigna or review Cigna s Summary of Benefits. annual s annual s annual s annual s ** annual s annual s annual s * ** Page 5
6 Surgical Sterilization Tubal Ligation Procedures annual s annual s annual s Vasectomy Procedures Other Benefits annual s annual s annual s Skilled Nursing Facility ; 100 day annual s; 100 day per ; 100 day annual s; 100 day per ; 100 day ; 100 day plan plan Durable Medical Equipment Diabetic Supplies Home Health Services Organ Transplants (Recipient) Chiropractic Services (Outpatient Short Term Rehab) ; 100 visit $40 co-pay, ; 20 visit benefit per plan annual s annual s; 100 visit per plan ; 20 visit benefit per plan ; 100 visit $60 co-pay, ; 20 visit benefit per plan annual s annual s; 100 visit per plan ; 20 visit benefit per plan ; 100 visit ; 20 visit benefit per plan ; 100 visit with individual organ s ; 20 visit benefit per plan Routine Eye Exams Not covered Not covered Not covered Not covered Not covered Not covered *Maximum is a combined limit for in-network and out-of-network benefits Page 6
7 Benefit Maximums* Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Mental Health No No No No No No Inpatient** Mental Health No No No No No No Outpatient** Substance Abuse No No No No No No Inpatient** Substance Abuse No No No No No No Outpatient** Chiropractic 20 visits/ 20 visits/ 20 visits/ 20 visits/ 20 visits/ 20 visits/ Outpatient Short- 60 days/ 60 days/ 60 days/ 60 days/ 60 days/ 60 days/ Term Rehabilitation Cardiac 36 days/ 36 days/ 36 days/ 36 days/ 36 days/ 36 days/ Rehabilitation Preventive Care No Limit Not Covered No Limit Not Covered No Limit Not Covered Skilled Nursing Facility 100/days per year 100/days per year 100/days per year 100/days per year 100/days per year 100/days per year *Maximum is a combined limit for in-network and out-of-network benefits total 20 visit chiropractic benefit limit per year **Benefits may be higher for some mental and nervous conditions when required by state statute. Page 7
(30- to 34-day supply) 100% after $40 copay; significant or new therapeutic class drugs: 50%
C O U N T Y S I N T R A N E T S I T E : H T T P : / / I N T R A N E T. C O. R I V E R S I D E. C A. U S 25 Exclusive Care Select Medicare Coordination Plan Tier 1: Exclusive Care Network Tier 2: Any Provider
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
Healthy New York Summary of Benefits
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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
CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) CERTIFICATE RIDER
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[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]](/thumbs/72/67333205.jpg "[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]
Shield Spectrum PPO Plan 1000 Value
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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
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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
PLAN DESIGN AND BENEFITS - NYC Community Plan SM 6-11 PARTICIPATING PROVIDER REFERRED*
Aetna Health Inc. for Referred Benefits Plan Effective Date: 10/1/2011 PLAN FEATURES Deductible (per calendar ) $5,000 Individual $15,000 Family Unless otherwise indicated, the Deductible must be met prior
Member Services
Member Services 1-800-589-4811 Plan Facts Hours of Operation Website Name of Physician Network Minute Clinic Decision Support Tools 8:00 a.m. to 6:00 p.m. Local Time Monday Friday www.aetna.com Aetna Choice
Not applicable. Immunizations 1 exam per 12 months for members age 18 to age 65; 1 exam per 12 months for adults age 65 and older.
PLAN FEATURES NON- Deductible (per calendar year) $300 Employee $600 Employee $900 Family $1,800 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
$8,300 $24,900 Maximum Lifetime Benefit
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$4,800 $9,600 Maximum Lifetime Benefit
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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)
Unlimited/ $1,000,000 per lifetime Primary Care Physician Selection
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PLAN FEATURES Deductible (per plan year) $2,500 Individual NON- $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All
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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
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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.
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
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 or by calling 1-800-477-8768. Important Questions
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
CA HMO Deductible $1,500 70%
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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):
Covered 100% 20% 1 exam per 12 months for members age 18 and older.
PLAN FEATURES NON- Deductible (per calendar year) $1,200 Individual $2,000 Individual $3,600 Family $6,000 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred
University of Cincinnati Medical Plan Summary and Comparison Non AAUP - Effective January 1- December 31, 2018
Annual Deductible Annual Health Savings Account Funding (UC) $1500 individual $3,000 family Varies by Annual Base Pay as of 1/1/18 $3,000 per person $6,000 family Varies by Annual Base Pay as of 1/1/18
MEDICAL SCHEDULE OF BENEFITS VALUE BRONZE
NON- LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes Deductible, Coinsurance, Copays and Precertification
Participating MEMBER RESPONSIBILITY
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MEDICAL SCHEDULE OF BENEFITS VALUE GOLD
NON- LIFETIME MAXIMUM BENEFIT CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes medical Deductible, medical Coinsurance, medical Copays
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
Super Blue Plus QHDHP 1 HDHP Non Emb 100%
Super Blue Plus QHDHP 1 HDHP Non Emb 100% Effective Date December 1, 2018 Benefit Period 2 (used for Deductible and Coinsurances limits and certain Contract Year benefit frequencies.) Note: All Services
Anthem Blue Cross Effective: January 1, 2018 Your Plan: University of California UC Care Plan Your Network: UC Select and Anthem Preferred
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PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
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
PLAN DESIGN AND BENEFITS - New York Open Access MC 3-11 HSA Compatible
PLAN FEATURES Deductible (per plan year) $3,000 Individual $6,000 Individual $6,000 Family $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
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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
Maximums Note: Out-of-Pocket maximum is the amount of covered expenses that you and/or your covered dependents will pay.
PRIORITY HEALTH priorityhealth.com PRIORITYHMO SUMMARY OF BENEFITS 100% HOSPITAL PLAN State of Michigan Active Plan October 14, 2012 - October 13, 2013 The following information is provided as a summary
MEDICAL SCHEDULE OF BENEFITS COPAY GOLD
NON- LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes Deductible, Coinsurance, Copays and Precertification
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An independent member of the Blue Shield Association California Trucking Association Health & Welfare Trust Access+ HMO SaveNet Facility Coinsurance 25-25% Benefit Summary (For groups of 300 and above)
PLAN DESIGN AND BENEFITS AETNA LIFE INSURANCE COMPANY - Insured
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AvMed In-Network Tier A Providers: $1,500 individual / $3,000 family AvMed In-Network Tier B Providers: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org or by calling 1-800-477-8768. Important Questions
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
Super Blue Plus QHDHP HDHP Non Emb 100%
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$300 Individual; $ 800 Family. Applies to out-of-network services only. What is the overall deductible?
What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.indecscorp.com or by
Retirees with Medicare (RETIREMENT DATE ON or AFTER March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2019
Pelican HRA1000 Magnolia Local Plus Network Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers Blue Cross and Blue Shield of Louisiana Preferred Care Providers
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Network Eligible OGB Members Pelican HRA1000 Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers Magnolia Local Plus Blue Cross and Blue Shield of Louisiana
Florida - EPO Aetna Select - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES
PLAN FEATURES Deductible (per calendar year) $100 Individual $200 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Pharmacy expenses do not apply towards the
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
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
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
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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
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Quarterly Premium Rate * Per Person $2,215.08 $1,789.50 $618.99 $890.70 Rates effective: 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 Eligibility Service
PLAN COMPARISON (Blue Cross Blue Shield of Massachusetts) For Members Who Are Eligible For Medicare
Quarterly Premium Rate * Per Person $2,358.60 $1,905.33 $658.74 $1,165.11 Rates effective: 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 Eligibility Service
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.
PLAN DESIGN & BENEFITS. $100 Individual/$200 Family $500 Individual/$1000 Family
PLAN FEATURES Deductible (per calendar year) Provider None $1000 Individual/$2000 Family Deductible (per calendar year) Facility Level A: Level B: $100 Individual/$200 Family $500 Individual/$1000 Family
Not applicable Optional. CHE PREFERRED CARE (Home Host) Covered 100%
PLAN FEATURES Catholic Health East PROVIDED BY LIFE INSURANCE COMPANY Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
Version: 15/02/2017 [ TPID: ] Page 1
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PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not required Deductible (per calendar year) $1,500 Individual $3,000 Family $3,000 Individual $9,000 Family
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
University of Cincinnati Medical Plan Summary and Comparison Effective January 1- December 31, 2018-AAUP only
Annual Deductible Annual Health Savings Account Funding (UC) $1500 individual $3,000 family Varies by Annual Base Pay as of 1/1/2018 $3,000 per person $6,000 family Varies by Annual Base Pay as of 1/1/2018
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
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
PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
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
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
ST. MARY S HEALTHCARE SYSTEM, INC.-CASE # GA6476 Blue Choice HI PPO Benefit Summary Effective: January 1, 2019
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Anthem Blue Cross Effective: January 1, 2018 Your Plan: University of California Health Savings Plan (HSP) Your Network: Anthem Prudent Buyer PPO
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SUMMARY OF BENEFITS Connecticut General Life Insurance Co.
SUMMARY OF BENEFITS General Life Insurance Co. Tolland and Tolland Public Schools (H.S.A) Health Savings Account Your coverage includes a health savings account that you can use to pay for eligible out-of-pocket
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)
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 https://eoc.anthem.com/eocdps/fi or by calling 1-800-542-9402.
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
$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
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
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)
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family All covered expenses, accumulate separately toward the preferred or
Non-Medicare Retirees (RETIREMENT DATE BEFORE March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2019
Network Pelican HRA1000 Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers Magnolia Local Plus Blue Cross and Blue Shield of Louisiana Preferred Care Providers
PLAN DESIGN AND BENEFITS - New York Open Access EPO 4-10/10 HSA Compatible
PLAN FEATURES Deductible (per plan year) $3,500 Individual $7,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Individual Deductible can only be met
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): 040, 041 Section Code(s): 3000, 3100 PPO - Flexible Blue 3, RX7 Effective Date: 01/01/2018 Benefits-at-a-glance This is intended
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): 036, 037 Section Code(s): 3000, 3100, 3300, 3400 PPO - Flexible Blue 2, RX6 Effective Date: 01/01/2018 -at-a-glance This is intended
You can see the specialist you choose without permission from this plan.
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.pibf.org or by calling 1-918-280-4800. Important Questions
Small Group HMO Coverage Period: Beginning on or after 05/01/2013
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. or by calling 1-800-376-6651. Important Questions
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
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
UConn Co-op Plan I: Grandfathered Coverage Period: 1/1/14 12/31/14
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.chpbenefits.com or by calling 1-800-633-7867. Important
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
PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK ( OUT-OF-NETWORK (Non- Deductible (per plan year) $350 Individual $800 Individual $1,050 Family $2,400 Family All covered expenses accumulate separately toward the preferred or
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