Standard Option Medical Schedule of Benefits (Effective January 01, 2018) Suburban Hospital Employees and Eligible Dependents
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1 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 $2500 $2500 Family $5000 $5000 Unlimited Included in EHP Network Provider Medical maximum Included in EHP Network Provider Medical maximum Acupuncture Allergy Tests & Procedures Medically necessary services for anesthesia, pain control, and therapeutic purposes 80% of ; deductible (15 visit annual maximum for all networks combined) 70% of R&C; deductible (15 visit annual maximum for all networks combined) Allergy tests 100% of ; deductible 70% of R&C; deductible Desensitization materials and serum 100% of ; deductible 70% of R&C; deductible Ambulance Transportation Medically necessary transport 80% of ; deductible 70% of R&C; deductible Biofeedback Chemo & Radiation Therapy Chiropractic Care Biofeedback Physician visit 80% of ; deductible 70% of R&C; deductible 100% (facility charge only) Materials and treatment 80% of ; deductible 70% of R&C; deductible 100% (facility charge only) Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) 80% of allowed amout; deductible (15 visit annual maximum for all networks combined) 70% of R&C; deductible (15 visit annual maximum for all networks combined) Refer to Therapy section Refer to Therapy section Refer to Therapy section Dialysis Medically necessary services 80% of ; deductible 70% of R&C; deductible Durable Medical Equipment Breast pumps (standard) and related supplies 100% of ; deductible 70% of R&C; deductible Contraceptive devices 100% of ; deductible 70% of R&C; deductible Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies 80% of ; deductible 70% of R&C; deductible 80% of ; deductible (preauthorization required; $250 lifetime maximum) 70% of R&C; deductible (pre-authorization required; $250 lifetime maximum) 80% of ; deductible 70% of R&C; deductible Hearing aids Not Covered Not Covered Non-custom medical equipment and supplies Prosthetic devices 80% of ; deductible 70% of R&C; deductible E00070 Page 1 of 6
2 Emergency Services Home Health Services Emergency care Emergency care (professional Medically necessary services Home infusion therapy $75 co-pay, then 90% of ; deductible (co-pay if admitted) $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of (copay if admitted) 90% of ; deductible 90% of R&C; deductible 90% of $20 co-pay; deductible (120 visit annual maximum; pre-authorization required) 70% of R&C; deductible (120 visit annual maximum; pre-authorization required) 70% of R&C; deductible Hospice Care Inpatient and home hospice 80% of ; deductible 70% of R&C; deductible Hospital Care Inpatient care including newborn nursery care; NICU $300 co-pay per admission, then 80% of ; deductible (for a service that Suburban does not provide: allowed amount; deductible ) Inpatient care 80% of ; deductible 70% of R&C; deductible 80% of Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care Observation care (professional Outpatient surgery & ambulatory surgical center Outpatient surgery & ambulatory surgical center (professional 80% of ; deductible (90 day annual maximum) 80% of ; deductible (60 day annual maximum) $75 co-pay, then 90% of ; deductible (co-pay if admitted) 70% of R&C; deductible (90 day annual maximum) 70% of R&C; deductible (60 day annual maximum) $75 co-pay, then 90% of R&C; deductible (co-pay if admitted) $75 co-pay, then 90% of (copay if admitted) 90% of ; deductible 90% of R&C; deductible 90% of 80% of ; deductible 70% of R&C; deductible 80% of Hyperbaric Oxygen Therapy Medically necessary services 80% of ; deductible 70% of R&C; deductible Immunizations Infusion Therapy Preventive immunizations for communicable diseases 100% of ; deductible 70% of R&C; deductible Travel immunizations 100% of ; deductible 70% of R&C; deductible Home infusion therapy Outpatient infusion therapy 70% of R&C; deductible E00070 Page 2 of 6
3 Injections Laboratory Mental Health & Substance Abuse Services Methadone Treatment Nutritional Counseling Injections 80% of ; deductible 70% of R&C; deductible Materials and serum 80% of ; deductible 70% of R&C; deductible Laboratory tests including pathology Outpatient mental health care Outpatient mental health care Inpatient mental health care Inpatient mental health care Outpatient substance abuse care Outpatient substance abuse care Inpatient substance abuse care Inpatient substance abuse care Intensive outpatient program Partial hospital facility services Medication management Mental health testing and procedures Medically necessary outpatient care Medically necessary services ; deductible 100% of ; deductible ; deductible 100% of ; deductible 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible $20 co-pay, then 100% of 70% of R&C; deductible 80% of ; deductible (limited to 6 visits 70% of ; deductible (limited to 6 visits per plan year for all networks combined; additional visits must per plan year for all networks combined; additional visits must be pre-authorized) be pre-authorized) Not available E00070 Page 3 of 6
4 Office Visits for Treatment of Illness or Injury Preventive Services Primary care office visit only (Adult) Primary care office visit (Pediatric: age 19 and under) Primary care office visit only (GYN) Specialty care office visit only (Adult & Pediatric) Treatment and diagnostic services in the office Preventive exam (PCP, GYN and Well Child care) Diagnostic services for preventive exam Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. $20 co-pay; deductible 70% of R&C; deductible $20 co-pay; deductible 70% of R&C; deductible $20 co-pay; deductible 70% of R&C; deductible $25 co-pay; deductible 70% of R&C; deductible 100% of ; deductible (limit one per plan year; birth to age one: 6 visit limit; age one to age two: 2 visit limit; age two to age six: 1 visit per plan year limit) 70% of R&C; deductible (limit one per plan year; birth to age one: 6 visit limit; age one to age two: 2 visit limit; age two to age six: 1 visit per plan year limit) 100% of ; deductible 100% of ; deductible (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) 70% of R&C; deductible (mammogram limited to one baseline exam between ages 35 to 39; one per plan year age 40 and up) Routine hearing exams $20 co-pay; deductible (limit one every 24 months) 70% of R&C; deductible (limit one every 24 months) Private Duty Nursing Private Duty Nursing 80% of ; deductible 70% of R&C; deductible Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound E00070 Page 4 of 6
5 Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment $25 co-pay; deductible 70% of R&C; deductible $25 co-pay, then 100% of ; for artificial insemination only, deductible (6 AI attempts lifetime maximum) pre-authorization required 70% of R&C for artificial insemination only, deductible (6 AI attempts lifetime maximum) pre-authorization required Birthing centers 100% of ; deductible 70% of R&C; deductible Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU Inpatient maternity care and delivery; newborn nursery care; NICU 100% of ; deductible 70% of R&C; deductible ; deductible 100% of ; deductible 70% of R&C; deductible Interruption of pregnancy Female sterilization (professional services for surgery, anesthesia and related pathology) Male sterilization (professional services for surgery, anesthesia and related pathology) Surgical treatment for morbid obesity Primary care office surgical procedures Specialist care office surgical procedures Outpatient surgery (including freestanding surgical centers) Outpatient surgery (including freestanding surgical centers) 100% of ; deductible 100% of ; deductible Covered at Johns Hopkins Bayview Medical Center and Sibley Memorial Hospital only. $300 co-pay per admission, then 80% of ; deductible, preauthorization required (Services paid as stated regardless of no availability at Suburban Hospital) Not Covered $20 co-pay; deductible 70% of R&C; deductible $25 co-pay; deductible 70% of R&C; deductible Inpatient surgery Inpatient surgery (professional E00070 Page 5 of 6
6 Therapy Urgent Care Center Habilitative services for children under the age of 19 Physical therapy/occupational therapy medically necessary services Speech therapy (nondevelopmental medically necessary services) 80% of ; deductible (preauthorization required) 80% of ; deductible (preauthorization required for visits > 12) 70% of R&C; deductible (pre-authorization required) 70% of R&C; deductible (pre-authorization required for visits > 12) 100% of (pre-authorization required for visits > 12) Pulmonary rehabilitation Cardiac rehabilitation Vision therapy Not Covered Not Covered Not Covered Physician visit $20 co-pay; deductible 70% of R&C; deductible Diagnostic services and treatment 100% of 70% of R&C; deductible E00070 Page 6 of 6
Standard Option Medical Schedule of Benefits (Effective January 01, 2017) Suburban Hospital Employees and Eligible Dependents
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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
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Benefit Modification for Members with Full PPO Savings Two-Tier Embedded Deductible 2250/2700/4500 Effective January 1, 2019 This chart is a summary of specific benefit changes to your plan. For a list
PLAN DESIGN & BENEFITS. $100 Individual/$200 Family $500 Individual/$1000 Family
PLAN FEATURES Deductible (per calendar year) Provider None $1000 Individual/$2000 Family Deductible (per calendar year) Facility Level A: Level B: $100 Individual/$200 Family $500 Individual/$1000 Family
SUPRO: 2018 SCHEDULE OF BENEFITS - EMPLOYEE COST SHARING
SU Pro (In- and Out-of-) In - Out -of- Cost Sharing Definitions Annual Deductible 1 Coinsurance Annual Out-of-Pocket Maximum 2 $200 per individual with a maximum of $400 for a family 5% of allowable amount
Emergency Department: $175 Copayment per visit Coinsurance: 0%
Schedule of Benefits UPMC Small Business Advantage Primary Care Provider: $25 Copayment per visit Gold PPO $1,000 $25/$50 - Premium Network Specialist: $50 Copayment per visit Deductible: $1,000 / $2,000
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
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
Full PPO Combined Deductible /60 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)
An independent member of the Blue Shield Association Full PPO Combined Deductible 25-250 90/60 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield
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 20, 2018 Effective Date: January 1, 2018 Schedule: 2A Booklet Base: 2 For: Choice POS II with Aetna HealthFund
Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum $2,000 per individual / $4,000 per family Lifetime Benefit Maximum
An independent member of the Blue Shield Association Access+HMO Per Admit 20-500 Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California
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
Summary of Benefits Prominence HealthFirst Small Group Health Plan
Prominence Nevada Gold A Plus In-Network Calendar Year Deductible (CYD) 2 $1,000 Single / $3,000 Family Summary of Benefits $2,000 Single / $6,000 Family Coinsurance - Member responsibility 20% coinsurance
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
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
Balance 3 up to Allowed Amount 4 after BCBSF pays up to $50. $0 CYD % Coinsurance 6
Understanding Your Share for Covered Services This health insurance policy 1 provides you with routine health care services, such as physician office services, as well as basic protection against major
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
Summary of Coverage. $6,350 / $12,700 (Includes Deductibles, Copays and Coinsurance Amounts) Preventive Care Covered at 100%
Benefits for 2017-2018 Medical Summary of Coverage Plan Features Blue Care Network HMO HRA IN NETWORK Purchased Deductible * Employee Deductible * $4,000 individual / $8,000 family * $500 individual /
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)
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
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): 040, 041 Section Code(s): 3000, 3100 PPO - Flexible Blue 3, RX7 Effective Date: 01/01/2018 Benefits-at-a-glance This is intended
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): 036, 037 Section Code(s): 3000, 3100, 3300, 3400 PPO - Flexible Blue 2, RX6 Effective Date: 01/01/2018 -at-a-glance This is intended
SHL Solutions PPO 25/750/80%
SHL Solutions PPO 25/750/80% Attachment A Benefit Schedule Lifetime Maximum Benefit for all Covered Services: Unlimited. Calendar Year Deductible (CYD): Your CYD is $750 of EME per Insured and $1,500 of
Simply Blue HDHP. General Information ROCHESTER REGIONAL HEALTH SYSTEM. Cost Sharing Expenses
ROCHESTER REGIONAL HEALTH SYSTEM Simply Blue HDHP $10/$30/$50 Subj. to Ded. Dom. $25/$50/$90 Subj. to Ded, No Ded Prev Rx Benefit Time Period: 01/01/2019-12/31/2019 General Cost Sharing Expenses Deductible
CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) CERTIFICATE RIDER
Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152 CONNECTICUT GENERAL LIFE INSURANCE COMPANY a CIGNA company (called CG) CERTIFICATE RIDER No. CR7BIASO5-3 Policyholder: