SoonerCare Traditional. SoonerCare Choice medically necessary Children Under 21 Adults 21 and Over Children Under 21 Adults 21 and Over
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1 SoonerCare Traditional SoonerCare Choice medically necessary Children Under 21 Adults 21 and Over Children Under 21 Adults 21 and Over Ambulance or emergency transportation - emergency only - emergency only - emergency only - emergency only Behavioral health and substance abuse services (some services may require prior authorization) - some services may require a $4 copay; Behavioral Health Inpatient - $7.50 per day, up to a maximum of $75 - some services may require a $4 copay; Behavioral Health Inpatient - $10 per day, up to a maximum of $75 Care management services for complex and/or unusual needs (prior authorization required) Child Health Wellness Screens (including health & immunization history; physical exams, various health assessments and counseling; lab & screening tests and necessary follow-up care) Dental services Cleaning twice a year, X-rays, fillings & crowns Emergency extractions Cleaning twice a year, X-rays, fillings & crowns Emergency extractions Diabetic supplies (100 glucose strips and lancets per month; one spring-loaded lancet device, three replacement batteries per year; Additional supplies require prior authorization), plus one glucometer per year - $4 per claim, plus one glucometer per year - $4 per claim Durable medical equipment when prescribed by require prior authorization when prescribed by require prior authorization. $4 copay per claim when prescribed by require prior authorization when prescribed by require prior authorization. $4 copay per claim Emergency Department (ER services) Family Planning services Pregnancy tests Pregnancy tests - Tubal ligations and vasectomies Pregnancy tests Pregnancy tests - Tubal ligations and vasectomies Hearing services Home health care services - evaluations, hearing aids and supplies without prior authorization when prescribed by a physician evaluation only without prior authorization when prescribed by a physician - $4 copay per visit - evaluations, hearing aids and supplies without prior authorization when prescribed by a physician evaluation only without prior authorization when prescribed by a physician - $4 copay per visit
2 SoonerCare Traditional SoonerCare Choice medically necessary Children Under 21 Adults 21 and Over Children Under 21 Adults 21 and Over Inpatient hospital services -$10 per day for first seven days - $5 on the eighth day -$10 per day for first seven days - $5 on the eighth day Immunizations (as recommended by the Advisory Committee of Immunization Practices) as recommended for adults; $4 per date of service as recommended for adults - $4 per date of service Laboratory and X-ray services - $4 per visit - $4 per visit Long-term care services Mammograms Nurse midwife and birthing center services Orthodontic services when prior authorized when prior authorized Outpatient hospital and surgery services medically necessary medically necessary - medically necessary medically necessary - Over-the-counter contraceptives Personal care as prescribed in as prescribed in as prescribed in as prescribed in Physician services Unlimited Medical Home/PCP 4 visits per month; including any visits. Up to 4 specialist or nonspecialist visits - $4 copay per PCP visits per month - $4 copay visit per visit Pregnancy and Maternity services (including prenatal, delivery and postpartum) * For Soon-to-be-Sooners, refer to the notes at the bottom of this document. Prescription drugs (Prenatal vitamins and smoking cessation products do not count towards prescription limits. No copays for children and pregnant women.) ** For Home and Community-Based Waiver Services copays, refer to the notes at the bottom of this document. Prosthetic devices Unlimited coverage when prior authorized; Orthotics are 6 per month limit; up to 2 brandname. $4 copay for each prescription. Limited coverage with prior authorization; Orthotics are Not Unlimited coverage when prior authorized; Orthotics are 6 per month limit; up to 2 brand name. $4 copay per prescription Limited coverage with prior authorization; Orthotics are Not Inpatient psychiatric services when prior authorized when prior authorized Residential substance abuse treatment services
3 SoonerCare Traditional SoonerCare Choice medically necessary Children Under 21 Adults 21 and Over Children Under 21 Adults 21 and Over SoonerRide - Transportation to non-emergency covered medical services Stop smoking (cessation) products 90 days without an authorization 90 days without an authorization 90 days without an authorization 90 days without an authorization Substance abuse treatment services (medical detoxification only) when prior authorized when prior authorized. Physical therapy (PT), Speech therapy (ST), Occupational therapy (OT) Services PT and OT - when prior authorized; initial evaluation does not require PA. ST - Evaluation and treatment require prior authorization. PT, ST, OT - no prior authorization required; 15 visits per year in hospital outpatient; PT and OT - when prior authorized; initial evaluation does not require PA. ST - Evaluation and treatment require prior authorization. PT, ST, OT - no prior authorization required; 15 visits per year in hospital outpatient; Transplant services when prior authorized when prior authorized when prior authorized when prior authorized Vision services Coverage for eye diseases or eye injuries only Coverage for eye diseases or eye injuries only * Soon-to-be-Sooners Members in Soon-to-be Sooners receive pregnancy and maternity services only. The individual who is covered for pregnancy-related benefits under Soon-to-be-Sooners retains eligibility until the end of pregnancy. Section 317: **Prescription Drugs for Home and Community- Based Services Members in Home and Community-Based Services waivers pay the following copays for prescriptions: $0.65 copay per drug costing $10.00 or less; $1.20 copay per drug costing $ $25.00; $2.40 copay per drug costing $ $50.00; $3.50 copay per drug costing $50.01 or more. The covered benefits list provided is not all-inclusive. All covered benefits must be medically necessary. Coverage of above benefits is dependent upon meeting requirements provided in accordance with various state and federal regulations. Refer to OAC 317: for further information related to cost sharing. Please verify coverage or consult with a SoonerCare or Insure Oklahoma Helpline representative prior to receiving services. Coverage, copays and limitations are subject to change. Refer to OHCA's pharmacy website for further information related to perscription drugs. Updated 08/24/2018
4 medically necessary SoonerPlan Insure Oklahoma Individual Plan Adults (IP) Ambulance or emergency transportation Behavioral health and substance abuse services (some services may require prior authorization) Care management services for complex and/or unusual needs (prior authorization required) Child Health Wellness Screens (including health & immunization history; physical exams, various health assessments and counseling; lab & screening tests and necessary follow-up care) Dental services Diabetic supplies (100 glucose strips and lancets per month; one spring-loaded lancet device, three replacement batteries per year; Additional supplies require prior authorization) Durable medical equipment - Psychiatrist visits included in 4 physician services limit per month. Physicians & Outpatient - ; Inpatient - $50 copay per admission Limited dental benefits for pregnant women, $0 copay; Emergency extractions - $4 copay when prescribed by medical provider with copay ($4 copay for durable, non-durable supplies; $8 copay for DME equipment) Emergency Department (ER services) - $30 copay (waived if admitted) Family Planning services Men and women age 19 and over - Birth control information, services and supplies. Gardasil for men and women through age 26. Tubal ligation & vasectomy for persons age 21 and older - $0 copay for any family planning-related service or supply supplies - Pap smears - Pregnancy tests - $0 copay; Tubal ligation and vasectomy for persons age 21 and older Hearing services Home health care services without prior authorization when prescribed by a physician -
5 medically necessary SoonerPlan Insure Oklahoma Individual Plan Adults (IP) Inpatient hospital services - $50 copay per admission Immunizations (as recommended by the Advisory Committee of Immunization Practices) Laboratory and X-ray services Long-term care services Mammograms Nurse midwife and birthing center services Orthodontic services Outpatient hospital and surgery services Over-the-counter contraceptives Personal care Services related to family planning only - $0 copay Services related to family planning only - $0 copay Contraceptives only - $0 copay as recommended for adults - $4 copay - $0 copay for standard radiology ($4 copay per specialized scan - MRI, MRA, PET, CT) - $0 copay medically necessary - $4 copay per visit. Therapeutic radiology - $4 copay per visit - $0 copay Physician services Physician visits and physical exams related to family planning only - $0 copay 4 visits per month; including any specialist visits - Pregnancy and Maternity services (including prenatal, delivery and postpartum) * For Soon-to-be-Sooners, refer to the notes at the bottom of this document. Prescription drugs (Prenatal vitamins and smoking cessation products do not count towards prescription limits. No copays for children and pregnant women.) ** For Home and Community-Based Waiver Services copays, refer to the notes at the bottom of this document. Prosthetic devices Inpatient psychiatric services Residential substance abuse treatment services Pregnancy tests for women - $0 copay Contraceptives only - $0 copay - $0 copay 6 per month limit; up to 2 brand-name; $4 copay for generic - $8 copay for brand name Limited coverage with prior authorization; orthotics are not covered Under Age 21 covered when prior authorized - $50 copay per admission; Age 21 and over - no coverage
6 medically necessary SoonerRide - Transportation to non-emergency covered medical services Stop smoking (cessation) products SoonerPlan Insure Oklahoma Individual Plan Adults (IP) 90 days without an authorization - $4 copay for generic; $8 copay for brand name Substance abuse treatment services (medical detoxification only) ; Outpatient - ; Inpatient - $50 copay per admission Physical therapy (PT), Speech therapy (ST), Occupational therapy (OT) Services PT, ST, OT - no prior authorization required; 15 visits per year in hospital outpatient; $4 copay per visit Transplant services Vision services Coverage for eye diseases or eye injuries only - $4 copay * Soon-to-be-Sooners **Prescription Drugs for Home and Community- Based Services The covered benefits list provided is not all-inclusive. All covered benefits must be medically necessary. Coverage of above benefits is dependent upon meeting requirements provided in accordance with various state and federal regulations. Refer to OAC 317: for further information related to cost sharing. Please verify coverage or consult with a SoonerCare or Insure Oklahoma Helpline representative prior to receiving services. Coverage, copays and limitations are subject to change. Refer to OHCA's pharmacy website for further information related to perscription drugs. Updated 08/24/2018
Plan changes are in red In-Network 2015 Out-of-Network
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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
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
$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
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
PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $500 Individual $500 Individual $1,500 Family $1,500 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred
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
$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
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
Covered 100%; deductible waived 50%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per plan year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the in-network or out-of-network
$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
SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co.
SUMMARY OF BENEFITS Ohio Associated Enterprises Health Savings Account Open Access Plus www.mycigna.com Member Services: (866) 494-2111 Cigna Health and Life Insurance Co. General Services In-Network Out-of-Network
$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
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
Retirees with Medicare (RETIREMENT DATE BEFORE March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2019
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
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
PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived 30% after deductible
PLAN FEATURES NON- Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred
Y o u r B e n e f i t s a t a G l a n c e Y o u r B e n e f i t s a t a G l a n c e
PRIME NETWORK The information contained in this Schedule of Benefits is not intended to provide a full description of eligible benefits, requirements and limitations. The full description, requirements
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
La Vie À l Ètranger Schedule of Benefits
www.wellaway.com La Vie À l Ètranger Schedule of Benefits www.wellaway.com Schedule of Benefits Coverage USA & Worldwide LA VIE À L ÉTRANGER/ SCHEDULE OF BENEFITS COST SHARE In-Network (USA) Out-of-Network
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
$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
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
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
GUIDE TO MEDICAL AND DENTAL PLANS
GUIDE TO MEDICAL AND DENTAL PLANS B e n e f i t s e f f e c t i v e J u l y 1, 2 0 1 4 t h r o u g h J u n e 3 0, 2 0 1 5 Choosing your benefits is an important decision. This guide provides you with the
$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