Schedule of Benefits Phoenix Health Plans, Inc.
|
|
- Georgia Reeves
- 6 years ago
- Views:
Transcription
1 Your Policy gives You important information about Your health care benefits. It includes information such as Pre-Authorization requirements. This Schedule of Benefits is issued to You with Your Policy. It summarizes Your benefits and gives their effective date. Please keep Your Schedule of Benefits with Your Policy. will notify You if any changes are needed. Coverage Information Policy Holder: Policy Number: [Policy Holder Name] [Policy Number] Plan Name: Phoenix Choice Silver HMO Abrazo and Phoenix Children s Hospital + Dental/Vision (73% AV CSR) Covered Person(s): Primary: [Member #1] Dependents: [Member #2] [Member #3] [Member ##] Date these benefits take effect: [Member #1] [Member #2] [Member #3] [Member ##] [MM/DD/YYYY] [MM/DD/YYYY] [MM/DD/YYYY] [MM/DD/YYYY] The applies to all Covered Services except: Preventive care services as defined under federal law and in Your Policy Primary care provider office visit (only the office copayment is exempt from the ) Specialist office visit (only the office copayment is exempt from the ) Routine pre/postnatal care Telehealth Urgent care Home health Outpatient lab (blood work) Diagnostic imaging (x-ray) Mental health/substance abuse office visit Diabetes care education Medical Foods gastric disorder formula and inherited metabolic disorder Pediatric vision services Other adult vision services Fitness benefit PHXSilverAPCHDV73_65441AZ Page 1 of 9
2 Prescription drugs Other dental care services (adult and pediatric) The renews each Plan Year. paid for Covered Services applies to the Annual Outof-Pocket Maximum. met in the current Plan Year does not carry over to the following year. If You have a Copayment and/or Coinsurance for a particular service and a, You must first pay the. The Copayment or Coinsurance is based on the remaining balance of Our approved amount. We will make payment to the provider only after Your cost sharing has been paid. Medical : Per Plan Year (for covered individual Member): $2600 Per Plan Year (for all covered family Members): $5200 Drug : Per Plan Year (for covered individual Member): $0 Per Plan Year (for all covered family Members): $0 Please note that separate s apply to pediatric and adult dental Covered Services. See Your Schedule of Benefits Dental for more information. Annual Out-of-Pocket Maximum The Annual Out-of-Pocket Maximum is the total amount You must pay during a Plan Year for Yourself and each Covered Dependent before We will Pay benefits at 100%. The Annual Out-of-Pocket Maximum does not include Premiums, balance-billed charges, claims with Non- without Our Pre-Authorization, adult dental services, other adult vision services, fitness benefit and health care the plan does not cover. Medical Out-of-Pocket Maximum: Per Plan Year (for covered individual Member): $5350 Per Plan Year (for all covered family Members): $10700 Drug Out-of-Pocket Maximum: Per Plan Year (for covered individual Member): Per Plan Year (for all covered family Members): Integrated with medical Integrated with medical Pediatric Dental Services Out-of-Pocket Maximum: PHXSilverAPCHDV73_65441AZ Page 2 of 9
3 Per Plan Year (for covered individual Member): Per Plan Year (for all covered family Members): Integrated with medical Integrated with medical Covered Services Services provided by Non- are excluded unless for Emergency Care, Emergency Ambulance, out-of-service Area Urgent Care or Pre-Authorized by Us Office Visits Primary Care Office Visit Specialist Office Visit $60 Copay per visit 100% of allowed costs Routine Prenatal/Postnatal Visit Telehealth Visit Preventive Care Physical Exams No charge 100% of allowed costs Please refer to the age and clinical Immunizations No charge 100% of allowed costs recommendation limitations as specified Screenings No charge 100% of allowed costs in the Policy Well-Baby/Child No charge 100% of allowed costs Emergency Medical & Urgent Care Emergency Room Services $150 Copay per visit after (Copay waived if admitted) 100% of allowed costs and Urgent Care Services $80 Copay per visit 100% of allowed costs Emergency Ambulance Services after PHXSilverAPCHDV73_65441AZ Page 3 of 9
4 Inpatient Hospital & Surgical Care Inpatient Hospital Care (including physician services, general nursing care and supplies) Reconstructive Surgery Breast Reconstruction Surgery and Post- Mastectomy Services Transplant Surgery and Travel Expenses Bariatric Surgery Maternity Services (including delivery and nursery care) Outpatient Surgery (including hospital and physician services) Ambulatory Surgery Care Services after after after after after after after after Alternatives to Hospital Care Skilled Nursing Hospice after after 90 days per Plan Year Home Health Care 0% Coinsurance 100% of allowed costs 42 visits per Plan Year Lab & Diagnostic Services Outpatient Lab (blood work) Diagnostic Imaging (x-ray) $40 Copay per visit (Copay not collected if test part of office visit) 100% of allowed costs $40 Copay per visit 100% of allowed costs PHXSilverAPCHDV73_65441AZ Page 4 of 9
5 (Copay not collected if test part of office visit) Imaging (CT, PET, MRI) after Mental Health Care & Substance Abuse Treatment Inpatient Mental Health Outpatient Mental Health (office visit) Outpatient Mental Health (outpatient facility) Inpatient Substance Abuse Outpatient Substance Abuse (office visit) Outpatient Substance Abuse (outpatient facility) after after after after Other Services Allergy (testing and treatment) after Autism Spectrum Disorder (therapies and services) after Cancer Clinical Trials (routine patient costs) after Chemotherapy after Chiropractic Care Services after 20 visits per Plan Year Dental Services (accidental dental, orthognathic surgery, TMJ) after PHXSilverAPCHDV73_65441AZ Page 5 of 9
6 Diabetes Care Education Diabetes Care Equipment and Supplies Dialysis Durable Medical Equipment (DME) Family Planning Foot Care (care for diabetes/diabeticrelated conditions) Habilitative Care Services Hearing Aid Hearing Exam Infusion/IV Medication Administration Therapy $0 Copay per visit 100% of allowed costs after after after after after after after after after Combined total of 60 visits per Plan Year 1 hearing aid per ear per Plan Year 1 hearing exam per Plan Year Medical Foods and Formula Gastric Disorder Formula Medical Foods and Formula Inherited Metabolic Disorder Nutritional Evaluation and Counseling 25% Coinsurance 75% of allowed costs 50% Coinsurance 50% of allowed costs after Prosthetic Devices after Rehabilitative Therapy after Combined total of 60 visits per Plan Year PHXSilverAPCHDV73_65441AZ Page 6 of 9
7 Vision Care Services Pediatric Vision Services (through month of 19th birthday) Adult Vision Screening Other Adult Vision Services $15 Copay per pair 100% of allowed costs after Copay after $25 Copay per visit 100% of allowed costs 1 eye exam per Plan Year 1 pair of eyeglasses per Plan Year (contact lenses, in lieu of eyeglasses, once per Plan Year when determined to be Medically Necessary and appropriate in the treatment of certain conditions) 1 vision screening, performed as part of annual physical to determine need for vision correction 1 eye exam per Plan Year $100 allowance per Plan Year for hardware Prescription Drugs Prescription Drug Amount for Covered Prescription Drugs You Pay Purchased from a Participating Retail Pharmacy Purchased from a Participating Retail or Mail-Order Pharmacy Purchased a Participating Mail- Order Pharmacy 1 to 30-Day 31 to 60-Day 61 to 90-Day 61 to 90-Day Preventive No charge No charge No charge No charge Tier 1 Preferred Generic Tier 2 Generic Tier 3 Preferred Brand $3 Copay per $10 Copay per $50 Copay per $6 Copay per $20 Copay per $100 Copay per $9 Copay per $30 Copay per $150 Copay per $7.50 Copay per $25 Copay per $125 Copay per PHXSilverAPCHDV73_65441AZ Page 7 of 9
8 Prescription Drug Tier 4 Non- Preferred Brand Tier 5 Preferred Specialty Tier 6 Non- Preferred Specialty Amount for Covered Prescription Drugs You Pay Purchased from a Participating Retail Pharmacy Purchased from a Participating Retail or Mail-Order Pharmacy 1 to 30-Day $100 Copay per 35% Coinsurance per 50% Coinsurance per 31 to 60-Day $200 Copay per 61 to 90-Day $300 Copay per Purchased a Participating Mail- Order Pharmacy 61 to 90-Day $250 Copay per NOTE: If You elect to get a brand name drug when the allows for a generic drug substitution, You may be responsible for the difference in cost between the generic and brand name drug. Fitness Benefit Policy Holders and their Covered Dependent spouse/domestic partner may be eligible to receive partial reimbursement for exercise facility/gym membership fees. Fees must be paid to the facility/gym to maintain equipment and programs that promote cardiovascular wellness. To be eligible, You must be an active member of the facility/gym and complete 50 visits in a six-month period. Reimbursement is the lesser of $200 for the Policy Holder and $100 for his/her Covered Dependent spouse/domestic partner OR the cost of membership for a six-month period. Please see Your Policy for details. Other Dental Care Services This plan covers the following types of dental care services for Members as follows: Pediatric Dental Services Pediatric dental benefits are available for Members through the month of their 19 th birthday. This plan includes coverage of pediatric dental services as required under the PPACA: Class I services: diagnostic and preventive services Class II services: restorative and other basic dental services Class III services: complex and major restorative dental services Class IV services: orthodontic services (Medically Necessary Orthodontic Treatment) NOTE: There is a waiting period of 24 months from the Effective Date of coverage for each Member under this Policy before that Member becomes eligible for Medically Necessary Orthodontic Treatment. Adult Dental Services PHXSilverAPCHDV73_65441AZ Page 8 of 9
9 Limited dental services in Class I and Class II are available for Members age 19 and older. The plan will cover up to $500 in Covered Services per Plan Year. NOTE: There is no coverage for Class III and Class IV adult dental services. We are partnering with DentaQuest to provide the pediatric and adult dental services that are covered under this plan. Covered Services are provided by DentaQuest. Please see the attached Schedule of Benefits Dental for a list of Covered Services by current dental terminology (CDT) code, Benefit Maximums/limitations, exclusions, cost shares and other important information. Please call Our Customer Service Department if You have any questions: (toll-free) or TTY: N. 16th, Suite 105 Phoenix, AZ (toll-free) TTY: PHXSilverAPCHDV73_65441AZ Page 9 of 9
Schedule of Benefits Allegian Health Plans
NOTE: This consumer choice health benefit plan does not include all state mandated health insurance benefits. The following benefit is provided at a reduced level from what is mandated: Mandated Benefit
More informationPlan 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
More informationSUBLUE AND SUORANGE: 2018 SCHEDULE OF BENEFITS -EMPLOYEE COST SHARING
Cost Sharing Definitions Annual Deductible 1 (amounts are not cumulative across levels) $100 per individual with a maximum of $250 for a family $300 per individual with a maximum of $1,000 for a family
More information[Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan]
[Plan Information] [Health Plan:] [Primary Member:] [Ambetter Secure Care 1 (2018) with 3 Free PCP Visits-Standard Gold On Exchange Plan] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]
More informationSUPRO: 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
More informationHealthTrust: Access Blue 20-RX10/20/45 Coverage Period: 07/01/ /30/2017
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.anthem.com or by calling 1-800-870-3122. Important Questions
More informationBlue 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
More informationBridgeSpan Health Company: BridgeSpan Oregon Standard Silver Plan Coverage Period: 01/01/2015
BridgeSpan Health Company: BridgeSpan Oregon Standard Silver Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015 01/01/2015 12/31/2015-12/31/2015 Coverage
More informationBridgeSpan Health Company: BridgeSpan Oregon Standard Silver Plan Value PPO
BridgeSpan Health Company: BridgeSpan Oregon Standard Silver Plan Value PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at www.bridgespanhealth.com.
More informationBlue Cross Silver, a Multi-State Plan 94
Blue Cross Silver, a Multi-State Plan 94 An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within BCBSM s unsurpassed statewide
More information01/01/ /31/2019 UMR: PALO PINTO GENERAL HOSPITAL:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 UMR: PALO PINTO GENERAL HOSPITAL: 7670-00-160036 001 Coverage for: Individual
More informationBlue Cross Silver, a Multi-State Plan 87
Blue Cross Silver, a Multi-State Plan 87 An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within BCBSM s unsurpassed statewide
More informationGold 1000 Revised 08/2018
Summary of Benefits - 2019 Individual Benefit Period* Deductible $1,000 $3,000 Family Benefit Period* Deductible (No member/insured may contribute more than the Individual Deductible amount toward the
More informationPLAN COMPARISON (Blue Cross Blue Shield of Massachusetts) For Members Who Are Eligible For Medicare
Quarterly Premium Rate * Per Person $2,215.08 $1,789.50 $618.99 $890.70 Rates effective: 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 Eligibility Service
More informationPLAN COMPARISON (Blue Cross Blue Shield of Massachusetts) For Members Who Are Eligible For Medicare
Quarterly Premium Rate * Per Person $2,358.60 $1,905.33 $658.74 $1,165.11 Rates effective: 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 Eligibility Service
More informationImportant 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.healthplan.memorialhermann.org or by calling 1-888-594-0671.
More informationNEW 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
More informationThe Harvard Pilgrim Best Buy ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Best Buy ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018 06/30/2019 Coverage for:
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More information$1,000/Individual, $2,000/Family per benefit period. What is the overall deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationThe Harvard Pilgrim Primary Choice HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Primary Choice HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018 06/30/2019 Coverage for: Individual
More informationSUMMARY 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
More information$6,300 person/ $12,600 family
: MyPriority HSA Bronze 6300 Coverage Period: Beginning o or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Subscriber/Dependent Plan Type: HMO This
More informationWhat is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket
Regence BlueShield: Regence Direct Silver with Dental, Vision, Individual Assistance Program Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers &
More informationSUPPLEMENT TO BROWN UNIVERSITY STUDENT HEALTH INSURANCE PROGRAM SUMMARY BROCHURE
SUPPLEMENT TO 2017-2018 BROWN UNIVERSITY STUDENT HEALTH INSURANCE PROGRAM SUMMARY BROCHURE This Supplement is designed to clarify additional specific benefits outlined in the Summary Brochure while the
More informationYou must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org or by calling 1-800-477-8768. Important Questions
More informationRegence BlueCross BlueShield of Oregon: Preferred Coverage Period: 07/01/ /31/2016
Regence BlueCross BlueShield of Oregon: Preferred Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2016 12/31/2016 Coverage for: Individual & Eligible Family
More informationChoice Easy Tier PPO Plus %/35% Coverage Period: On or after 1/1/2019. You don t have to meet deductibles for specific services.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationBridgeSpan Health Company: BridgeSpan Silver HDHP 2000 MyChoice Northwest
BridgeSpan Health Company: BridgeSpan Silver HDHP 2000 MyChoice Northwest Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 12/31/2016 Coverage for: Individual
More informationImportant Questions Answers Why this Matters:
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationImportant Questions Answers Why This Matters: What is the overall deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: MIDDLESEX COUNTY IMPROVEMENT AUTHORITY POS Coverage for:
More informationCost if you use a Non-Network Provider. Cost if you use an In-Network Provider. Covered Medical Benefits
Anthem Blue Cross Life and Health Insurance Company Student Health Plan: Samuel Merritt University Your Plan: Custom PPO 300/20/40/20 Your Network: Prudent Buyer PPO This summary of benefits is a brief
More informationCoverage for: Single Enrollee Plan Type: TRAD/PPO. Important Questions Answers Why This Matters: $2,500/single Network $5,000/single Non-Network
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 STRS OHIO : Basic Plan with Medicare Part B Only Coverage for: Single
More informationAnthem BlueCross BlueShield Christian Care Communities Blue Access PPO Coverage Period: 01/01/ /31/2015 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.anthem.com or by calling 1-888-650-4047. Important Questions
More informationBest Buy HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HMO 500 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2018 03/31/2019 Coverage for: Individual + Family
More informationSummary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/ /31/2019.
Summary of and : What This Plan Covers & What You Pay for Covered Services Period: 01/01/2019-12/31/2019 Important Questions What is the overall deductible? Are there services covered before you meet your
More informationCigna Health and Life Insurance Co.
SUMMARY OF BENEFITS Kass Shuler, P.A. Open Access Plus - Preferred www.mycigna.com Member Services 866-494-2111 Cigna Health and Life Insurance Co. Notice of Grandfathered Plan Status This plan is being
More informationSUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1
SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1 General Services In-Network Out-of-Network Physician office visit Primary Care Physician (PCP) Physician Office Visit
More informationHMO - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts HMO - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Coverage for: Individual + Family Plan Type:
More informationImportant 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.crystalrunhp.com or by calling 1-844-638-6506. Important
More information$2,000/Individual, $4,000/Family per benefit period. What is the overall deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationSHL 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
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationCommunityCare : 1CCS CommunityCare Silver Coverage Period: 01/01/2014 -
CommunityCare : 1CCS CommunityCare Silver Coverage Period: 01/01/2014 - Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: HMO Summary This of Benefits
More informationSummary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 09/01/2018 08/31/2019 Aetna: Select Open Access Coverage for: Individual, Parent/Child, Employee/Spouse,
More informationNationwide Life Ins. Co.: SUNY Maritime College Coverage Period: 8/11/13 8/10/14
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.chpstudent.com or by calling 1-800-633-7867. Important
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 through 12/31/2018 Community Value HMO (Silver) - 94% CSR Coverage for: Individual
More information01/01/ /31/2018 FLORIDA SCHOOLS HEALTH INSURANCE PROG:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 FLORIDA SCHOOLS HEALTH INSURANCE PROG: 7670-00-410536 010 020 Coverage
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/ /30/2019
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018 06/30/2019 HealthTrust: Lumenos Preferred Blue Coverage for: Individual/Family Plan
More information$2,000/Individual, $4,000/Family per benefit period. What is the overall deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationCompanion Life Insurance Company: New England Culinary Institute Coverage Period: 7/1/14-7/1/15
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.chpstudent.com or by calling 1-800-633-7867. Important
More informationImportant 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 https://eoc.anthem.com/eocdps/aso or by calling (855) 333-5735.
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationSUMMARY OF BENEFITS Fisk University Open Access Plus -BUY-UP PLAN Effective 10/1/2015 Customer Service:
SUMMARY OF BENEFITS Fisk University Open Access Plus -BUY-UP PLAN Effective www.mycigna.com Customer Service: 866-494-2111 Cigna Health and Life Insurance Co. General Services In-Network Out-of-Network
More informationYour Plan: Anthem Silver PPO 3400/0%/3400 w/hsa Your Network: Anthem PPO
Your Plan: Anthem Silver PPO 3400/0%/3400 w/hsa Your Network: Anthem PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not
More information2019 Summary of Benefits
2019 Summary of Benefits CHRISTUS Health Plan Generations H1189, Plan 001 This is a summary of drug and health services covered by CHRISTUS Health Plan Generations, January 1, 2019 December 31, 2019. CHRISTUS
More informationMaine's Choice HSA HMO 5000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Maine Maine's Choice HSA HMO 5000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan
More informationSummary of Benefits. January 1, 2018 December 31, Providence Medicare Harbor + RX (HMO) Providence Medicare Summit + RX (HMO-POS)
Summary of Benefits January 1, 2018 December 31, 2018 These Plans are available in Snohomish and King Counties in Washington. 2018 Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and
More informationMySHL Solutions PPO Platinum 2
MySHL Solutions PPO Platinum 2 Attachment A Benefit Schedule Lifetime Maximum Benefit for all Covered Services: Unlimited Calendar Year Deductible ( CYD ): There is no Calendar Year Deductible for Plan
More informationAre there services covered before you meet your deductible? Yes. Preventive care is covered before you meet your deductible.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Horizon BCBSNJ: MIDDLESEX COUNTY ROOSEVELT CARE CENTER Coverage for: All
More informationRetirees 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
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationRetirees 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
More informationIn-network: $5,000 single / $10,000 family per calendar year. Out-of-network: $10,000 per insured per
Regence BlueShield: Regence Direct Bronze HSA Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationWhat is the overall deductible? Are there services covered before you meet your deductible?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationWhat is the overall deductible? See the Common Medical Events chart below for your costs for services this plan covers.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationSCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center
SCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center The following Schedule of Benefits is part of your Certificate of Coverage. It sets forth benefit limits
More informationImportant Questions Answers Why this Matters:
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: about the cost
More informationElevateHealth Gold 1000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
New Hampshire ElevateHealth Gold 1000 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family
More informationImportant 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.healthplan.memorialhermann.org or by calling 1-888-594-0671.
More informationIn-Network (IN): $2,000/Individual, $4,000/Family per benefit period. Out-of-Network (OON): $4,000/Individual, $8,000/Family per benefit period.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationSuper Blue Plus QHDHP HDHP Non Emb 100%
Super Blue Plus QHDHP 1 2017 HDHP Non Emb 100% Effective Date April 1, 2018 to November 31, 2018, then restart December 1, 2018. Benefit Period (used for Deductible and Coinsurances limits and certain
More informationStandard Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Standard Gold Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan Type:
More informationBridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO
BridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at www.bridgespanhealth.com.
More informationMEDICAL SCHEDULE OF BENEFITS COPAY GOLD
LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes medical Deductible, medical Coinsurance, medical Copays
More informationCoverage for: Individual + Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 FELRA & UFCW VEBA Fund: Plan I Coverage for: Individual + Family Plan
More informationImportant 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.anthem.com/ca or by calling 1-855-333-5730. Important
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationNationwide Life Ins. Co.: Ithaca College Coverage Period: 8/10/13-8/9/14
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.chpstudent.com or by calling 1-800-633-7867. Important
More informationUnitedHealthcare: Choice Plus HRA Coverage Period: 01/01/ /31/2015 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.myuhc.com or by calling 1-866-314-0335. Important Questions
More informationStandard Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Standard Bronze Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family Plan Type:
More information: POS HD 3000 Silver Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS
Standard Silver Point-of-Service 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.connecticare.com or
More informationThe Harvard Pilgrim HMO
Massachusetts The Harvard Pilgrim HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Individual + Family
More informationAvMed Network: $1,500 individual / $3,000 family Doesn t apply to preventive care. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org or by calling 1-800-376-6651. Important Questions
More informationAnthem Blue Cross Your Plan: Premier HMO 10/100% - MUST Trust Your Network: California Care HMO
Anthem Blue Cross Your Plan: Premier HMO 10/100% - MUST Trust Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.
More information2019 Summary of Benefits
2019 Summary of Benefits CHRISTUS Health Plan Generations Plus H1189, Plan 002 This is a summary of drug and health services covered by CHRISTUS Health Plan Generations Plus, January 1, 2019 December 31,
More informationThe Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts The Harvard Pilgrim Best Buy HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 12/01/2017 11/30/2018 Coverage for: Individual
More informationCoverage for: All Coverage Tiers Plan Type: POS. 1 of 9
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.paramounthealthcare.com or by calling 1-800-462-3589.
More informationPEIA 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
More informationBest Buy HMO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HMO 2000 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 03/31/2018 Coverage for: Individual + Family
More informationCoverage for: Individual/Family Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
More informationAnthem Blue Cross Blue Shield: Anthem Silver DirectAccess - cbka Coverage Period: 01/01/ /31/2014
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.anthem.com or by calling 1-888-231-5046. Important Questions
More informationY 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
More informationCHRISTUS Health Plan Generations (HMO) Summary of Benefits. Finally, access to the doctor and hospital you know and trust. christushealthplan.
CHRISTUS Health Plan Generations Summary of Benefits Finally, access to the doctor and hospital you know and trust. christushealthplan.org Summary of Benefits CHRISTUS Health Plan Generations H1189 This
More informationSchedule 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
More informationImportant 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.healthplan.memorialhermann.org or by calling 1-888-594-0671.
More informationBMC HealthNet Plan: Bronze Saver/Bronze Low Coverage Period: 08/01/ /31/2013 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.bmchp.org or by calling 1-877-492-6967. Important Questions
More informationAnthem 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
More information