Open Choice J-1 Visa Plan Coverage Period: 01/01/ /31/2017
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1 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 or by calling Important What is the overall? Are there other s for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to No. see a specialist? Are there services this Yes. plan doesn't cover? Answers For each Calendar Year the Individual is $500 and the Family is $1,000 No. Yes, for this Plan the out-of-pocket limit is $2,500 ind./$5,000 family. For the Prescription Plan the In-Network limit is$3,500 ind./$7,000 family. Premiums, balance-billed charges, penalties for failure to obtain preauthorization for services, and health care this plan doesn t cover. No. Yes. For a list of in-network providers, see or call You may also utilize out-of-network providers. Why this Matters: You must pay all the costs up to the amount before this plan begins to pay for covered services you use. The starts over every January 1st. See the chart starting on page 2 for how much you pay for covered services after you meet the. You don t have to meet s for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. While you may utilize any hospital, facility or physician of your choice, if you utilize a provider in Aetna s Open Choice PPO network, you may be able to take advantage of Aetna s negotiated rates which may lower your out-of-pocket expenses. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. If you aren t clear about any of the terms used in this form, see the Glossary at Page 1 of 8
2 Copayments are fixed dollar amounts (for example, $10) you pay toward the cost of each prescription. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower s, and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit In-Network Provider Out-Of-Network Provider Limitations & Exceptions Chiropractic visits limited to 20 per year, Nutrition visits limited to 12 per year. Preventive care/screening/ immunization Age and frequency schedules may apply. If you have a test Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) If you aren t clear about any of the terms used in this form, see the Glossary at Page 2 of 8
3 Common Medical Event If you need drugs to treat your illness or condition (Prescription coverage is provided by OptumRx.) More information about prescription drug coverage is available at mycatamaranrx. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Preferred Brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency Room Services Emergency Medical Transportation Urgent Care Facility fee (e.g., hospital room) Physician/surgeon fee In-Network Provider $5 copay (retail) $10 copay (mail order) $25 copay (retail) $50 copay (mail order) $40 copay (retail) $80 copay (mail order) If a generic equivalent exists, see "Limitations & Exceptions" for cost Same costs as above categories Out-Of-Network Provider $5 copay (retail) $10 copay (mail order) $25 copay (retail) $50 copay (mail order) $40 copay (retail) $80 copay (mail order) If a generic equivalent exists, see "Limitations & Exceptions" for cost Same costs as above categories Limitations & Exceptions Covers up to a 30-day supply (retail); day supply (mail order). If a maintenance medication is purchased at a retail pharmacy for more than 3 months, subsequent refills will cost twice the retail copayment rate. Some prescriptions may require Prior Authorization, Step Therapy and Quantity Duration Programs. If there is a generic equivalent for a brand-name drug, Member pays the generic copay plus the difference between the Plan's cost of the brand drug and the Plan's cost of the generic drug. Most Specialty drugs must be purchased through OptumRx Specialty Pharmacy, BriovaRx. Not covered for non-emergency use. If you aren t clear about any of the terms used in this form, see the Glossary at Page 3 of 8
4 Common Medical Services You Out-Of-Network Event May Need In-Network Provider Provider Limitations & Exceptions Mental/Behavioral health outpatient If you have mental health, behavioral Mental/Behavioral health inpatient health, or substance abuse needs Substance use disorder outpatient Substance use disorder inpatient Prenatal and If you are pregnant postnatal care Delivery and all inpatient services Home health care Coverage limited to 60 visits per calendar year. If you need help recovering or have other special health needs Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Limited to 30 visits per calendar year each for Speech, Occupational and Physical Therapies and a separate 50 visits per calendar year for pulmonary and cardiac rehab. Age and visit limits may apply. 60 days per calendar year maximum. Inpatient -180 days per lifetime maximum. If you aren t clear about any of the terms used in this form, see the Glossary at Page 4 of 8
5 If you need dental or eye care Services You May Need Limitations & Exceptions Eye exam Not covered Not covered Not covered under J-1 Visa Plan; covered under the MetLife Vision Plan if elected. Glasses Not covered Not covered Not covered under J-1 Visa Plan; covered under the MetLife Vision Plan if elected. Dental check-up In-Network Provider Not covered Your Cost If You Use an Out-Of- Network Provider Not covered Not covered under J-1 Visa Plan; covered under Aetna or MetLife Dental Plans if elected. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture (except in lieu of anesthesia) Glasses Weight loss programs Cosmetic surgery Long-term care Routine eye care Routine foot care Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Nutritionist (limited to 12 visits per year) Hearing aids - up to $1,500 every 3 years Infertility treatment - Diagnosis & treatment of underlying medical condition covered with no lifetime Chiropractic care (limited to 20 visits per year) Non-emergency care when traveling outside the maximum. Other infertility treatment limited to $20,000 U.S. lifetime maximum. Specific treatments may have lifetime attempt limits. Proof of inability to conceive is not Private-duty nursing required for treatment. If you aren t clear about any of the terms used in this form, see the Glossary at Page 5 of 8
6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna at , the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Additionally, a consumer assistance program can help you file an appeal. Contact information is at Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (acturial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 如果需要中文的帮助, 请拨打这个号码 Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. If you aren t clear about any of the terms used in this form, see the Glossary at Page 6 of 8
7 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $ 7,540 Amount owed to providers: Plan pays: $ 5,642 Plan pays: $ 4,200 Patient pays $ 1,898 Patient pays: $ 1,200 Having a baby (normal delivery) Sample care costs: Hospital charges (mother) $ 2,700 Prescriptions $ 2,900 Routine obstetric care $ 2,100 Medical Equipment and Supplies $ 1,300 Hospital charges (baby) $ 900 Office Visits and Procedures $ 700 Anesthesia $ 900 Education $ 300 Laboratory tests $ 500 Laboratory tests $ 100 Prescriptions $ 200 Vaccines, other preventive $ 100 Radiology Vaccines, other preventive $ $ $ 5,400 Total $ 7,540 Deductibles $ 500 Patient pays: Copays ** $ 240 Deductibles $ 500 Coinsurance $ 460 Copays * $ 30 Limits or exclusions $ - $ 1,368 $ 1,200 Coinsurance Limits or exclusions $ - Total $ 1,898 *Assumes 3 Mail Order copays for generic prescriptions **Assumes 4 Mail Order generic prescriptions and 4 Mail Order Preferred Brand prescriptions If you aren t clear about any of the terms used in this form, see the Glossary at Page 7 of 8 Managing type 2 diabetes (routine maintenance of a well-controlled condition) $ 5,400
8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-ofnetwork providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how s, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box for each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, s, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. If you aren t clear about any of the terms used in this form, see the Glossary at Page 8 of 8
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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.healthnet.com or by calling 1-800-522-0088. Important
More informationKENT STATE UNIVERSITY: 80/60 PPO 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 Medical Mutual 800-586-4509, Anthem at 866-811-9727 or CVS
More informationPanther Gold Advantage: UPMC Health Plan Coverage Period: 07/01/ /30/2016 Summary of Coverage: What this Plan Covers & What it Costs
Panther Gold Advantage: UPMC Health Plan Coverage Period: 07/01/2015-06/30/2016 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All coverage levels Plan Type: HMO This is only
More informationImportant Questions Answers Why this Matters: 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.healthnet.com or by calling 1-800-522-0088. Important
More informationImportant Questions Answers Why this Matters: 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.healthnet.com or by calling 1-800-522-0088. Important
More informationImportant Questions Answers Why this Matters: 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.healthnet.com or by calling 1-800-522-0088. Important
More informationPremera BC: AWB Plan F 5000T $5,000 Deductible (NGF) Coverage Period: Beginning on or after 12/01/2015
Premera BC: AWB Plan F 5000T $5,000 Deductible (NGF) Coverage Period: Beginning on or after 12/01/2015 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan
More informationThis 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
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.bcbswny.com or by calling 1-888-249-2583. Important Questions
More informationHealth Alliance HMO 100 Rx28 NS1 Coverage Period: 01/01/ /31/2016
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.healthalliance.org. or by calling 1-800-851-3379. Important
More informationdocument at or by calling Important Questions Answers Why This Matters: 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.bcbsla.com or by calling 1-800-495-2583. Important Questions
More informationImportant Questions Answers Why this Matters: 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.healthnet.com/edison or by calling 1-888-893-1572. Important
More informationImportant Questions. What is the overall deductible?
Important Questions 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.ebms.com or by calling 1-866-312-6723.
More informationBlueOptions Healthy Rewards HRA Coverage Period: 01/01/ /31/2015
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.floridablue.com or by calling 1-800-664-5295. In the
More informationMidwestern Intermediate Unit #4: QHDHP Coverage Period: 01/01/ /31/2016
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.miu4.k12.pa.us or by calling (724)458-6700 ext. 1202.
More informationEven though you pay these expenses, they do not count toward the outof-pocket limit.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at https://www.healthplansinc.com/members/benefits.aspx or by calling
More information1 of 8. 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 www.sbstpa.com or by calling 1-504-323-7500/1-866-342-0182.
More informationChoice Plus Health Savings Plan Discount Tire/America s Tire/Discount Tire Direct
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.myuhc.com or by calling 1-855-837-1612. Important Questions
More information$3,500 person / $7,000 family For non-preferred providers
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.blueshieldca.com or by calling 888-852-5345. Important
More information$0. See the chart starting on page 2 for your costs for services this plan covers.
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.healthnet.com or by calling 1-800-847-3991. Important
More informationNational Allied Workers Union Insurance Trust Fund Plan IIIB Coverage Period: 04/01/ /31/2018
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.aegisadmin.com or by calling 1-773-889-2307. Important
More informationBlue Shield of CA: Shield PPO Split Deductible 20/500 Coverage Period: Beginning on or after 1/1/2013
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.blueshieldca.com or by calling 1-800-424-6521. Important
More informationSkyWest CDHP - Value 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.skywestonline.com or by calling 1-866-287-3470. Important
More informationGeneral Mills: Murfreesboro Coverage Period: 01/01/ /31/2013
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.healthpartners.com/gmtn or by calling 1-888-324-9722.
More informationYou 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.livetheorangelife.com or by calling 1-800-555-4954. Important
More informationSt. Charles CUSD #303 HMOI: Blue Cross and Blue Shield of Illinois Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage:
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.d303.org or by calling 1-331-228-4929. Important Questions
More informationYou don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs and for services this plan covers.
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.bcbswny.com or by calling 1-866-231-0847. Important Questions
More informationChoice Plus Traditional Plan Coverage Period: 01/01/ /31/2015
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.bsabenefits.mercerhrs.com or by calling 1-800-444-4416.
More informationYou don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
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.bsneny.com or by calling 1-800-888-1238. Important Questions
More informationBCBS: Health Savings PPO Coverage Period: 01/01/ /31/17
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.bcbsm.com or by calling 866-917-7537. Important Questions
More informationBlue Shield of California: 80-C $20; Rx 7-25 Coverage Period: 10/01/ /30/2015
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.blueshieldca.com or by calling 1-800-642-6155. Important
More informationAetna Comprehensive Traditional Plan Coverage Period: 01/01/ /31/2014
This is only a summary. If you want more detail about your coverage and costs, please refer to your 2014 Annual Enrollment materials and carrier contact information, as well as the Bank of America Employee
More informationYou don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
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.bsneny.com or by calling 1-800-888-1238. Important Questions
More informationHighmark Blue Cross Blue Shield: PPO 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.highmarkbcbs.com or by calling 1-800-299-1910. Important
More informationSilver $3,250/$10 Partner Network: UPMC Health Plan Coverage Period: 01/01/ /31/2015 Summary of Coverage: What this Plan Covers & What it Costs
Silver $3,250/$10 Partner Network: UPMC Health Plan Coverage Period: 01/01/2015-12/31/2015 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: All coverage levels Plan Type: EPO This
More informationHealth Alliance HMO 5000c Silver Coverage Period: 01/01/ /31/2015
Health Alliance HMO 5000c Silver Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual + Family Plan Type: HMO This is
More informationCoverage for: Single/Family Plan Type: PPO. 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 www.bcbswny.com or by calling 1-888-249-2583. Important Questions
More informationBlueCross BlueShield of WNY: Gold PPO 7100
BlueCross BlueShield of WNY: Gold PPO 7100 Coverage Beginning on or After: 01/01/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the
More informationSummary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type: PPO
BlueOptions 5801 Coverage Period: 12/01/2013-11/30/2014 with Rx $10 Generic Only Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and/or Family Plan Type:
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