Highlights of your Health Care Coverage Washington Counties Insurance Fund
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1 Highlights of your Health Care Coverage Washington Counties Insurance Fund Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay. Effective Date: 01/01/2018 MEDICAL PLAN MEDICAL COST SHARE OPTIONS Individual Deductible PCY (Family aggregate deductible 2x Individual) Coinsurance (Member's percentage of costs after deductible based on allowable charges) Individual Out of PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family aggregate OOP Max 2X Individual) Office Visit Cost Share PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION Preventive Office Visit (Unlimited, subject to standard medical guidelines) Immunizations (Unlimited, subject to standard medical guidelines) Health Education (HE) (Unlimited) Nicotine Dependency Programs (ND) (Unlimited) Diabetes Health Education (DE) (Unlimited) Individual Deductible: $1,500; Family aggregate Deductible: $3,000 Shared with In-Network 20% 50% Individual OOP Max: $3,400; Family aggregate OOP Maximum $6,800 Covered In Full Shared with In-Network Out of Pocket Maximum 1-9J08HA Rev #1 Q 8/18/ :05 AM Page 1 of 7
2 PROFESSIONAL CARE Professional Office Visit Inpatient Professional Services Contraceptive Management Services (Unlimited) DIAGNOSTIC SERVICE OPTIONS Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA Other Professional Diagnostic Imaging Other Professional Diagnostic Laboratory/Pathology Diagnostic Mammography FACILITY CARE OPTIONS Inpatient Facility Outpatient Surgery Facility Skilled Nursing Facility (90 Days PCY) Hospice Inpatient Facility (14 Days; 6 month limit per lifetime) EMERGENCY CARE AND TRANSPORTATION OPTION Covered In Full Covered In Full Deductible, then covered in full, applies to Out of Deductible, then covered in full, applies to Out of 1-9J08HA Rev #1 Q 8/18/ :05 AM Page 2 of 7
3 Emergency Care Emergency Room Physician Urgent Care Center Ambulance Transportation (Unlimited) Air Ambulance (Unlimited) OTHER SERVICES Allergy/Therapeutic Injections Mental Health Inpatient Facility Care (Unlimited) Mental Health Outpatient Professional Care (Unlimited) Chemical Dependency Inpatient Facility Care (Unlimited) Chemical Dependency Outpatient Professional Care (Unlimited) Rehab Inpatient Facility (30 days PCY) Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy, and Chronic Pain (45 visits PCY) or Family aggregate Out of or Family aggregate Out of or Family aggregate Out of or Family aggregate Out of 1-9J08HA Rev #1 Q 8/18/ :05 AM Page 3 of 7
4 Rehab Outpatient Care Chronic Conditions, Including Cardiac, Pulmonary Rehab, and Cancer Medical Supplies, Equipment, Prosthetics (Unlimited) Foot Orthotics, Orthopedic Shoes and Accessories ($300 PCY; Includes orthotics and orthopedic shoes) Home Health Visits (130 visits PCY) Hospice Care (Respite 240 hours; 6 months lifetime max) TMJ (Temporomandibular Joint Disorders) (Unlimited (Medical and Dental services - Medical and Dental cost shares based on type of service)) Transplants (Unlimited; $7,500 travel and lodging limits) Drug List Prescription Drugs - Retail (Specific preventive drugs and legend Retail: 90 day supply/mail: 90 day supply/specialty: 30 day supply) Prescription Drugs - Mail (Specific preventive drugs and legend Retail: 90 day supply/mail: 90 day supply/specialty: 30 day supply) Specialty Pharmacy (Mandatory) ALTERNATIVE CARE Manipulations (Spinal and other) (Spinal Manipulations 20 Visits PCY Massage Therapy 12 Visit PCY separate from Spinal Manipulations) Acupuncture (12 Visits PCY) SUPPLEMENTAL BENEFITS Deductible, then covered in full, applies to the Out of Covered as any other service Covered as any other service Open A1 No Tiers Covered as any other service Open A1 No Tiers Not Covered Not Covered 1-9J08HA Rev #1 Q 8/18/ :05 AM Page 4 of 7
5 Routine Vision Exam (1 PCY) Pediatric Vision Exam (1 PCY under age 19) ANNUAL PLAN MAXIMUM Annual Plan Maximum Unlimited Unlimited Prior Authorization is required for many services to be covered. For more information please refer to your benefit booklet. PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue cross. Members are responsible for amounts in excess of the allowable charge. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-9J08HA Rev #1 Q 8/18/ :05 AM Page 5 of 7
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Highlights of your Health Care Coverage Washington Counties Insurance Fund
Highlights of your Health Care Coverage Washington Counties Insurance Fund Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after
Highlights of your Health Care Coverage Washington Counties Insurance Fund
Highlights of your Health Care Coverage Washington Counties Insurance Fund Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after
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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
Personal Choice Trinity Health
Personal Choice Trinity Health Essential Assist PPO Personal Choice our popular Preferred Provider Organization (PPO), gives you freedom of choice by allowing you to choose your own doctors and hospitals.
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
Summary of Benefits Prominence HealthFirst Small Group Health Plan
Prominence Nevada Gold A Plus In-Network Calendar Year Deductible (CYD) 2 $1,000 Single / $3,000 Family Summary of Benefits $2,000 Single / $6,000 Family Coinsurance - Member responsibility 20% coinsurance
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
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:
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
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
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