LOCKHEED MARTIN AERONAUTICS COMPANY MARIETTA 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY
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- Stella Poole
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1 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 Office Visits Specialist Office Visits Single: $500; Family: $1,500 (with no more than $500 per person); in-network and out-of-network are not combined; they do not cross apply Single: $1,500; Family: $3,000 (with no more than $1,500 per person); in-network and out-of-network are not combined; they do not cross apply No maximum Single: $1,500; Family: $4,500 (with no more than $1,500 per person); in-network and out-of-network are not combined; they do not cross apply; Out of Area (OOA) same as network benefit and cross applies with out-of-network Single: $5,000; Family: $10,000 (with no more than $5,000 per person); in-network and out-of-network are not combined; they do not cross apply; Out of Area (OOA) same as network benefit and cross applies with out-of-network No maximum Aexcel Designated Provider: 90% after deductible; Non-Aexcel Designated Provider: 85% after deductible 65% (80% OOA) after deductible 1 of 8 February 24, 2011
2 Prescription Drugs Retail: Generic Drugs/Tier 1 Drugs Retail: Preferred Brand- Name Drugs/Tier 2 Drugs Retail: Non-Preferred Brand-Name Drugs/Tier 3 Drugs Mail Order: Generic Drugs/Tier 1 Drugs Mail Order: Preferred Brand-Name Drugs/Tier 2 Drugs Mail Order: Non- Preferred Brand-Name Drugs/Tier 3 Drugs Preventive Care Up to a 30-day supply you pay: 10% up to $25 maximum, for Up to a 30-day supply you pay: 30% up to $75 maximum, for Up to a 30-day supply you pay: 50% up to $175 maximum, for Up to a 90-day supply you pay: 10% up to $50 maximum, for Up to a 90-day supply you pay: 30% up to $150 maximum, for Up to a 90-day supply you pay: 50% up to $350 maximum, for Up to a 30-day supply you pay: 50%, no deductible Up to a 30-day supply you pay: 50%, no deductible Up to a 30-day supply you pay: 50%, no deductible No Coverage No Coverage No Coverage Flu Shot 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Immunizations: Adult 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Immunizations: Child 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) 2 of 8 February 24, 2011
3 Mammograms 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Occult Blood Stool Test 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Prostate Screening Antigen (PSA) Test Routine Pap Smear (Including Exam and Related Lab Fees) Routine Physical Exam - Adult 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Well Child Care 100%, deductible waived (age and frequency limitations apply) 100%, deductible waived (age and frequency limitations apply) Outpatient Acupuncture 85% after deductible (limitations apply) 65% (80% OOA) after deductible (limitations apply) Allergy Tests Allergy Treatment Ambulance 85% after deductible 85% after deductible Cardiac Rehabilitation Chiropractic Colonoscopy Contraceptive Devices and Implants 85% after deductible; up to 20 visits per calendar year (combined in-network and out-of-network limit) 85% after deductible (if not included as part of preventive screening) 65% (80% OOA) after deductible; up to 20 visits per calendar year (combined in-network and out-of-network limit) 65% (80% OOA) after deductible (if not included as part of preventive screening) 3 of 8 February 24, 2011
4 Diagnostic Testing: Routine Laboratory Diagnostic Testing: Specialized Tests, i.e. MRI, CAT, PET, Ultrasound Diagnostic Testing: X- rays Durable Medical Equipment 85% after deductible; precertification required for recognized charges in excess of $5,000 recognized charges in excess of $5,000 Emergency Room Care 85% after deductible 85% after deductible Hearing Screenings Hearing Aids Infertility: Artificial Insemination Infertility: In Vitro Fertilization Infertility: Reversal of Voluntary Sterilization Maternity: Birthing Center Delivery Maternity: Midwife Delivery Maternity: Prenatal Office Visits 85% after deductible; limited to $1,000 per ear every 3 calendar years (combined in-network and out-of-network limit) 65% (80% OOA) after deductible; limited to $1,000 per ear every 3 calendar years (combined in-network and out-ofnetwork limit) 4 of 8 February 24, 2011
5 Occupational Therapy Outpatient Surgery - Ambulatory Surgical Facility Setting Outpatient Surgery - Hospital Setting 85% after deductible Limited to 60 visits per calendar year combined for speech, physical and occupational therapies. Short-term rehabilitation, combination of office and outpatient treatment in a facility, is included in the 60-visit maximum (combined in-network and out-of-network limit) 65% (80% OOA) after deductible Limited to 60 visits per calendar year combined for speech, physical and occupational therapies. Short-term rehabilitation, combination of office and outpatient treatment in a facility, is included in the 60-visit maximum (combined in-network and out-of-network limit) Physical Therapy Podiatry Sigmoidoscopy 85% after deductible (if not included as part of preventive screening) 65% (80% OOA) after deductible (if not included as part of preventive screening) Speech Therapy 85% after deductible Limited to 60 visits per calendar year combined for speech, physical and occupational therapies. Short-term rehabilitation, combination of office and outpatient treatment in a facility, is included in the 60-visit maximum (combined in-network and out-of-network limit) 65% (80% OOA) after deductible Limited to 60 visits per calendar year combined for speech, physical and occupational therapies. Short-term rehabilitation, combination of office and outpatient treatment in a facility, is included in the 60-visit maximum (combined in-network and out-of-network limit) Tubal Ligation Urgent Care Center Vasectomy 5 of 8 February 24, 2011
6 Inpatient Hospital Hospital Room and Board 85% after deductible; precertification required 65% (80% OOA) after deductible; precertification required Laboratory and Other Maternity Delivery Organ or Tissue Transplants Institute of Excellence (IOE) Facility: 90% after deductible; Other Facilities: 85% after deductible; requires preauthorization by National Medical Excellence 65% (80% OOA) after deductible; requires preauthorization by National Medical Excellence Physician Mental Health and Substance Abuse Mental Health: Inpatient 85% after deductible; precertification required 65% (80% OOA) after deductible; precertification required Mental Health: Outpatient Substance Abuse: Inpatient 85% after deductible; precertification required 65% (80% OOA) after deductible; precertification required Substance Abuse: Outpatient 6 of 8 February 24, 2011
7 Other Dental: Accidental Injury to Teeth 85% after deductible; precertification required 65% (80% OOA) after deductible; precertification required Dental: Implants Dental Home Health Care 85% after deductible; up to 120 visits per calendar year (Home Health Care and Private Duty Nursing visits combined); precertification required (combined in-network and out-ofnetwork limit) 65% (80% OOA) after deductible; up to 120 visits per calendar year (Home Health Care and Private Duty Nursing visits combined); precertification required (combined in-network and out-of-network limit) Hospice Care 85% after deductible; precertification required 65% (80% OOA) after deductible; precertification required Oral Surgery: Removal of Tumors, Cysts, and Impacted Teeth 85% after deductible; covers accident related to injury to teeth, and medical in nature oral and jaw surgery; precertification required 65% (80% OOA) after deductible; covers accident related to injury to teeth, and medical in nature oral and jaw surgery; precertification required Orthotics Private Duty Nursing 85% after deductible; up to 120 visits per calendar year (Home Health Care and Private Duty Nursing visits combined); precertification required (combined in-network and out-ofnetwork limit) 65% (80% OOA) after deductible; up to 120 visits per calendar year (Home Health Care and Private Duty Nursing visits combined); precertification required (combined in-network and out-of-network limit) Prosthetic Appliances 85% after deductible; precertification required for recognized charges in excess of $5,000 recognized charges in excess of $5,000 7 of 8 February 24, 2011
8 Skilled Nursing Facility 85% after deductible; up to 120 days per calendar year; precertification required (combined in-network and out-ofnetwork limits) 65% (80% OOA) after deductible; up to 120 days per calendar year; precertification required (combined in-network and outof-network limits) Vision: Screenings/Eye Refraction Vision: Lenses/Frames/Contacts Covered only as part of routine physical exam Covered only as part of routine physical exam Healthy Actions Healthy Actions Universal Incentives: Not Applicable Universal Incentive Annual Maximum: Not Applicable Other Incentive: Not Applicable Health Fund: Not Applicable 8 of 8 February 24, 2011
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
Benefits At A Glance
Benefits At A Glance In-Network Out-Network Annual Deductibles and Out-of-Pocket Maximums Deductible Individual An upfront $1,500 deductible per covered member will apply An upfront $3,000 deductible per
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
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
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
PEIA PPB Plan A Benefits At a Glance
PEIA PPB Plan A Benefits At a Glance Benefit Description PEIA PPB Plan A In-Network PEIA PPB Plan A Out-of-Network Annual deductible Varies by salary and employer type. See premium charts. Twice the in-network
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.
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
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
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
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
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
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
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
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
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
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
Florida Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012. PLAN DESIGN AND BENEFITS MC OA Plan A-50
Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS MC OA Plan 12-3000A-50 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS
Florida Health Network Option (POS Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Option (POS Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOption Plan 12-2000-70 PLAN FEATURES PARTICIPATING PROVIDERS
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
Florida Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS Deductible (per calendar year) PLAN DESIGN
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
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
This is not an ERISA plan. Please contact your Employer for additional information. Aetna Select Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK
Schedule of Benefits Employer: Alief Independent School District ASA: 100085 Issue Date: September 20, 2016 Effective Date: September 1, 2016 Schedule: 4A Booklet Base: 4 For: Aexcel Plus Aetna Select
PLAN DESIGN AND BENEFITS - NJ HMO HSA COMPATIBLE NO-REFERRAL 3.1 CALYR (OVR50%/UND50%)
PLAN FEATURES Deductible (per calendar year) $2,500 Single Subscriber $5,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Single Subscriber Deductible
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
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.
Florida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-80 HSA PLAN FEATURES Deductible (per calendar
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
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)
NEW CASTLE COUNTY COMPARISON OF PRE-65 RETIREES/PENSIONERS BENEFITS PLAN YEAR 2019
Deductible Per Calendar Year (Individual/Family) $200 Individual $400 Family (DME, Prosthetics and Hearing Aids only) $200 per Individual $400 per Family $200 per Individual $400 per Family $200 per Individual
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
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
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
$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
Florida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-Compass PLAN FEATURES Deductible (per calendar
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
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)
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
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
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. $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
Connecticut Small Group Open Access QPOS Aetna Health Inc. Plan Effective Date: 10/1/2010 Aetna Health Insurance Company
PLAN FEATURES Deductible (per calendar year) $2,000 Individual NON- $3,000 Individual $4,000 Family $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
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
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 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
PPO HSA HDHP $2,500 90/50
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $2,500 Individual $5,000 Family $5,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member
$4,000 Family. $7,150 Individual $14,300 Family
PLAN DESIGN AND BENEFITS - CA Silver Basic HMO 2000 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable
$8,000 Family. $6,600 Individual $13,200 Family
PLAN DESIGN AND BENEFITS - GA OAMC 4000 100/70 (2018) GA Group Business 51-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not Required Not Required Deductible
$10,000 Family. $7,000 Individual $14,000 Family
PLAN DESIGN AND BENEFITS - NV Silver AWH Las Vegas HMO 5000 $30 (2018) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable
PLAN DESIGN AND BENEFITS - PA POS HSA COMPATIBLE NO-REFERRAL 2.4 ($2,500 Ded) PARTICIPATING PROVIDERS
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
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
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
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
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
$7,000 Family. $7,500 Individual $15,000 Family
PLAN DESIGN AND BENEFITS - NV Silver AWH Las Vegas HMO 3500 80% $40 (2019) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not
PLAN DESIGN AND BENEFITS - NJ POS HSA COMPATIBLE NO-REFERRAL 3.1 CALYR (OVR50%/UND50%) $2,500 Single Subscriber
PLAN FEATURES Deductible (per calendar year) $2,500 Single Subscriber $5,000 Single Subscriber $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being
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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
$7,000 Family. $7,150 Individual $14,300 Family
PLAN DESIGN AND BENEFITS - MD Silver HNOnly SJ 3500 100% (2017) MD Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
$11,000 Family. $6,600 Individual $13,200 Family
PLAN DESIGN AND BENEFITS - CA Bronze Basic HMO Deductible 5500 (01/15)(2015) CA Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not
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
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
$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
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
$14,000 Family. $7,000 Individual. $14,000 Family
PLAN DESIGN AND BENEFITS - NV Bronze PPO 7000 100/70 (2017) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA)
THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA) Effective Date: 01-01-2016 PLAN FEATURES Annual Deductible $1,500 Employee $3,000 Employee $3,000 Employee + 1 Dependent
THE MITRE CORPORATION Aetna PPO High Deductible Plan with a Health Saving Account (HSA)
THE MITRE CORPORATION Aetna PPO High Deductible Plan with a Health Saving Account (HSA) Effective Date: 01-01-2017 PLAN FEATURES Annual Deductible $1,500 Employee $3,000 Employee $3,000 Employee + 1 Dependent
$8,000 Family. $6,000 Individual $12,000 Family
PLAN DESIGN AND BENEFITS - FL Silver HNOnly 4000 100 (2016) FL Group Business 2-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
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
$5,000 Family. $6,800 Individual $13,600 Family
PLAN DESIGN AND BENEFITS - NV Silver PPO 2500 70/50 (2018) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
Unlimited unless otherwise indicated.
PLAN FEATURES PARTICIPATING NON-PARTICIPATING Deductible (per calendar year) $1,000 Individual $5,000 Individual $2,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior
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
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
PREFERRED CARE. Covered 100%; deductible waived Not Covered
PLAN FEATURES NON- Deductible (per calendar year) $1,300 Individual $1,300 Individual $2,600 Family $2,600 Family All covered expenses including prescription drugs accumulate toward both the preferred
20% After deductible PREFERRED CARE. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including nonpreventive prescription drugs, accumulate toward both the
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.
$6,000 Individual $12,000 Family
PLAN DESIGN AND BENEFITS - CA Gold MC 0 80/50 (2018) (2018) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not required Deductible
$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
PLAN DESIGN AND BENEFITS - CA
PLAN DESIGN AND BENEFITS - CA Gold PPO 750 80/50 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
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 - 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
Community Blue SM PPO Plan 12A Benefits-at-a-Glance
Community Blue SM PPO Plan 12A 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
$3,000 Family. $4,000 Individual $8,000 Family
PLAN DESIGN AND BENEFITS - FL Gold HNOption 1500 80 (2016) FL Group Business 2-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not required Deductible
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
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
Annual deductibles and maximums In-network Out-of-network Lifetime maximum
SUMMARY OF BENEFITS City of Richmond & Richmond Public Schools (Plan B) Connecticut General Life Insurance Co. Annual deductibles and maximums Lifetime maximum Unlimited per individual Pre-Existing Condition
Aetna Health Inc. New Jersey Small Group QPOS Open Access
PLAN FEATURES NETWORK Deductible (per calendar year) Not Applicable $1,000 Individual $2,000 Family Deductible applies to all covered expenses unless otherwise indicated. Once the Family Deductible is
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
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
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
Unlimited/ $1,000,000 per lifetime Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Member Coinsurance Out-of-Pocket Maximum $1,500 $3,000 Individual (per calendar year) $3,000 $6,000 Family Member cost sharing for
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
$4,000 Family. $6,350 Individual $12,700 Family
PLAN DESIGN AND BENEFITS - PA Silver PPO 2000 100/50 (2015) PA Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
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
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
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 -
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.
Not Applicable. $5,000 Individual. 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 $2,000 per member Not Applicable $2,000 per member (2-member maximum)
$5,400 Family. $6,650 Individual $13,300 Family
PLAN DESIGN AND BENEFITS - WA Silver PPO 2700 80/50 HSA-E (2019) WA Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Appendix A. Prepared Exclusively for The Dow Chemical Company
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