La Vie À l Ètranger Schedule of Benefits
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1 La Vie À l Ètranger Schedule of Benefits
2 Schedule of Benefits
3 Coverage USA & Worldwide LA VIE À L ÉTRANGER/ SCHEDULE OF BENEFITS COST SHARE In-Network (USA) Out-of-Network (USA) Worldwide Annual Limits Unlimited Unlimited 1,000,000 The amount you owe for certain health care services, as indicated below. 4,500 Individual 9,000 Family 9,000 Individual 18,000 Family No deductible Coinsurance Your share of costs on a covered health care service. 30% 50% No coinsurance Annual out-of-pocket maximum This amount is the maximum you will pay each benefit period. s, coinsurance and co-payments are included in reaching this amount. 7,150 Individual 14,300 Family 14,300 Individual 28,600 Family No Out-of-Pocket Maximum HOSPITALIZATION Hospitalization (inpatient care) then 30% then 50% Rehabilitative services (inpatient care) then 30% then 50% Physician services (inpatient care) then 30% then 50% Psychiatric hospitalization then 30% then 50% Emergency medical transportation 110 copay 110 copay 40 copay WELLNESS CARE Routine physical exams/preventative care up to 200 Cancer screening (mammogram, pap test, prostate) up to 200 WellAway LA VIE À l ÉTRANGER 3
4 LA VIE À L ÉTRANGER/ SCHEDULE OF BENEFITS PRESCRIPTION DRUGS Coverage USA & Worldwide In-Network (USA) Out-of-Network (USA) Worldwide Preventive (e.g. oral contraceptives) Generic 15 copay 15 copay Brand 30 copay 15 copay Non-preferred brands 60 copay 60 copay Specialty (purchase from specialty pharmacy) 110 copay 60 copay MATERNITY CARE Prenatal and postnatal consultations (UCR) up to the maximum amount Labor and delivery - hospital stay then 30% 300 copay less CFE reimbursement up to a maximum of 10,000 Birthing center 310 copay Not applicable Newborn care then 30% 300 copay less CFE reimbursement up to a maximum of 10,000 Congenital anomaly (e.g. cleft lip/ palate) then 30% 300 copay less CFE reimbursement up to a maximum of 10,000 Infertility treatment Sterilization (e.g. tubal ligations and vasectomies) 300 copay less CFE reimbursement up to a maximum of 10,000 WellAway LA VIE À l ÉTRANGER 4
5 Coverage USA & Worldwide LA VIE À L ÉTRANGER/ SCHEDULE OF BENEFITS OUTPATIENT CARE In-Network (USA) Out-of-Network (USA) Worldwide Urgent care center 60 copay 110 copay Not Applicable Emergency room (waived with hospital admission) 260 copay 260 copay Outpatient hospital facility & surgical care then 30% Skilled nursing facility (limited to 20 visits) 260 copay/day (780 limit) Not Applicable General consultation / primary care visit 30 copay up to a maximum allowable of 55 including Specialist consultation 50 copay up to a maximum allowable of 85 including Psychiatric consultation 50 copay 100% up to a maximum allowable of 85 including up to a maximum of 10 visits per year Laboratory tests (independent clinical lab) 60 copay then 30% (UCR) Basic radiology (x-ray, ultrasound) 60 copay then 30% (UCR) Advanced radiology (MRI, CT, MRA) 110 copay (UCR) Durable medical equipment then 30% 50 copay less Rehabilitation and habilitation services 40 copay 100 copay less Physical & speech therapy, spinal manipulation Cancer treatment, drugs & reconstructive surgery then 30% then 30% 30 copay per visit (limited to 20 visits) 300 copay less Dialysis 310 copay, deductible then 30% 300 copay less EVACUATION & REPATRIATION Medical evacuation Transfer to the nearest medical facility if the treatment the member needs is not available locally. Medical repatriation Members can return to their country of origin to be treated as long as physically and medically stable. Repatriation of mortal remains up to 120,000 Limit per covered person, per benefit period up to 50,000 Lifetime limit per covered person up to 25,000 Lifetime limit per covered person WellAway LA VIE À l ÉTRANGER 5
6 CHILD WELLNESS CARE Coverage USA & Worldwide LA VIE À L ÉTRANGER/ SCHEDULE OF BENEFITS In-Network (USA) Out-of-Network (USA) Worldwide Routine child exams & immunizations up to 200 Annual routine tests up to 200 Routine dental exams for children under 19 up to 200 Eye exams for children under 19 up to 200 Eye glasses for children under 19 up to 200 LA VIE À l ÉTRANGER Optional Coverage DENTAL AND VISION COVERAGE (OPTIONAL) FIRST YEAR SECOND YEAR THIRD YEAR Maximum Benefit 3,500 per policy year Basic (routine) 65% 80% 90% 100 lifetime Major Restorative 25% 50% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Orthodontic Treatment (covered for children under the age of 19-1,200 lifetime maximum per child, 600 annual limit) 10% 25% 50% Vision Care Routine Vision Exam 75, 10 copay (one vision exam per year - includes any fees for contact lense fittings) Lenses (single vision, bifocal, trifocal) Frames (limited to one per benefit period) Contact Lenses (in lieu of frames) up to 225 (limited to one every 24 months) up to 200 up to 100 CFE benefits are primary to WellAway benefits. Out-of-Pocket costs are reimbursed according to the CFE fee schedule. Copays at the hospital do not apply if the CFE reimburses directly. For information on CFE benefits, please refer to the CFE schedule. IMPORTANT NOTE: If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. All benefits are subject to Usual Reasonable and Customary Fees (UCR). All benefits reflected in USD. WellAway LA VIE À l ÉTRANGER 6
7 This material is provided for informational purposes only and is subject to change. The information contained in this schedule of benefits does and will not affect, modify or supersede in any way the policy terms and conditions. This document shall not bind WellAway Limited or require WellAway Limited to offer or write any insurance at any particular rate or to any particular group or individual. The actual premium and benefits are governed by your policy documents. All benefits are subject to exclusions and limitations. To ensure you have all the information you need before purchasing one of our products, we recommend you consult with your independent medical, legal and/or tax advisors. If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. Products and services may not be available in all jurisdictions and are expressly excluded where prohibited by applicable law. The contents of this material are the exclusive intellectual property of WellAway Limited. No reproduction, changes or copying is possible without the consent of WellAway Limited. The WellAway name, brand and logos are the registered marks of WellAway Limited and WellAway SA, Hamilton, Bermuda. WellAway LA VIE À l ÉTRANGER 7
8 CONTACT US Bermuda: UK: France: Belgium: Skype: info@wellaway.com WellAway Limited Canon s Court, 22 Victoria Street Hamilton HM 12, Bermuda Rev. 05/2018
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Summary of Benefits - 2019 Individual Benefit Period* Deductible $1,000 $3,000 Family Benefit Period* Deductible (No member/insured may contribute more than the Individual Deductible amount toward the
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
Participating MEMBER RESPONSIBILITY
Deductible 80% $500 Preferred Provider Organization Underwritten by Coventry Health and Life Insurance Company (d.b.a. HealthAmerica) DEDUCTIBLES AND MAXIMUMS Annual Deductible Individual $500 $1,000 Family
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
PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY CHE PREFERRED CARE (Home Host)
PLAN FEATURES PROVIDED BY LIFE INSURANCE COMPANY CHE NON- Deductible ( year) None Individual $200 Individual $500 Individual None Family $400 Family $1,000 Family All covered expenses accumulate toward
AvMed Network: $1,500 individual / $3,000 family Doesn t apply to preventive care. 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 1-800-376-6651. Important Questions
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 or by calling 1-800-376-6651. Important Questions
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 2751 Centerville Road, Suite 400 Wilmington, Delaware SCHEDULE OF BENEFITS.
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 2751 Centerville Road, Suite 400 Wilmington, Delaware 19808-1627 SCHEDULE OF BENEFITS CoventryOne SM CoventryOne is administered by Coventry Health Care of Delaware,
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
PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
Proprietary PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $750 Individual $20,000 Individual $2,000 Family $40,000 Family All covered expenses accumulate simultaneously toward
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
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
Covered 100%; deductible waived 30%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $2,000 Individual $20,000 Individual $4,000 Family $40,000 Family All covered expenses accumulate simultaneously toward both the preferred
CHE PREFERRED CARE (Home Host)
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
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