Medical Schedule of Benefits (Effective January 01, 2016) Johns Hopkins Bayview Medical Center Non-Union and Union Employees and Eligible Dependents
|
|
- Kelly Blake
- 6 years ago
- Views:
Transcription
1 Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Hopkins Preferred Network Provider Individual $100 $750 $0 Family $200 $1500 $0 Individual $2000 $3500 Family $4000 $7000 Unlimited Included in EHP Network Provider Medical maximum Included in EHP Network Provider Medical maximum Acupuncture Allergy Tests & Procedures for anesthesia, pain control, and therapeutic purposes $30 co-pay for office visit, then 100% of allowed amount; deductible applies ($1500 annual maximum for all networks combined) 70% of R&C; deductible applies ($1500 annual maximum for $30 co-pay for office visit, then 100% of allowed amount; ($1500 annual maximum for Allergy tests Desensitization materials and serum Ambulance Transportation Medically necessary transport 100% of allowed amount; deductible waived 100% of R&C; deductible waived 100% of allowed amount Biofeedback Biofeedback Not Covered Not Covered Not Covered Chemo & Radiation Therapy Chiropractic Care Dialysis Durable Medical Equipment Physician visit $30 co-pay of allowed amount; deductible applies 70% of R&C; deductible applies $30 co-pay of allowed amount Materials and treatment Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) Breast pumps (standard) and related supplies $15 co-pay for office visit, then 100% of allowed amount; deductible applies ($1500 annual maximum for all networks combined) 70% of R&C; deductible applies ($1500 annual maximum for $15 co-pay for office visit, then 100% of allowed amount; ($1500 annual maximum for Refer to Therapy section Refer to Therapy section Refer to Therapy section 90% of allowed amount; deductible applies; 100% at Davita Dialysis Centers; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; deductible waived 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; includes Davita Dialysis Centers (pre-authorization 100% of allowed amount for Johns Hopkins Home Care Group/Pharmaquip Contraceptive devices Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies Hearing aids Non-custom medical equipment and supplies Prosthetic devices 100% of allowed amount; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; (pre-authorization ; 100% of allowed amount; deductible waived (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 70% of R&C; deductible applies (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 90% of allowed amount; deductible applies 70% of R&C; deductible applies 100% of allowed amount; deductible waived (pre-authorization 70% of R&C; deductible applies (pre-authorization 100% of allowed amount; (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 100% of allowed amount for Johns Hopkins Home Care Group/Pharmaquip 100% of allowed amount; (pre-authorization E00006, E00007, E00161 Page 1 of 6
2 Emergency Services Home Health Services Hospice Care Hospital Care Hyperbaric Oxygen Therapy Immunizations Infusion Therapy Emergency care Emergency care (professional Home infusion therapy Inpatient and home hospice Inpatient care including newborn nursery care; NICU $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $150 co-pay, then 100% of R&C; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $150 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage 100% of allowed amount; deductible waived 100% of R&C; deductible waived 100% of allowed amount 100% of allowed amount; deductible waived (40 visits per year maximum for all networks combined; pre-authorization 100% of allowed amount; deductible waived (pre-authorization $150 co-pay per admission, then 90% of allowed amount; deductible waived (semi-private, unless private room is medically necessary; pre-authorization 70% of R&C; deductible applies (40 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization applies (semi-private, unless private room is medically necessary; pre-authorization 100% of allowed amount; (40 visits per year maximum for all networks combined; preauthorization 100% of allowed amount for services through Johns Hopkins Home Care Group (preauthorization allowed amount (semi-private, unless private room is medically necessary; pre-authorization Inpatient care Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care Observation care (professional Outpatient surgery & ambulatory surgical center Outpatient surgery & ambulatory surgical center Preventive immunizations for communicable diseases First 30 days covered at 100% of allowed amount, remaining days at 90% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization First 30 days covered at 100% of allowed amount, remaining days at 90% of allowed amount; deductible applies (120 days per year maximum all networks combined for medically necessary services; pre-authorization $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; preauthorization 70% of R&C; deductible applies (120 days per year maximum all networks combined for medically necessary services; preauthorization $150 co-pay, then 100% of allowed amount; deductible waived (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 100% of allowed amount (120 days per year maximum all networks combined for medically necessary services; pre-authorization 100% of allowed amount (120 days per year maximum all networks combined for medically necessary services; pre-authorization $150 co-pay, then 100% of allowed amount (if admitted, observation co-pay waived; see Inpatient Facility Care for coverage) 100% of allowed amount; deductible waived 100% of allowed amount; deductible waived 100% of allowed amount 90% of allowed amount; deductible applies (includes 90% of allowed amount; deductible applies (includes outpatient testing prior to outpatient surgery) 70% of R&C; deductible applies (includes freestanding surgical centers) 70% of R&C; deductible applies (includes outpatient testing prior to outpatient surgery) 70% of R&C; deductible applies (pre-authorization 100% of allowed amount (includes 100% of allowed amount (includes outpatient testing prior to outpatient surgery) Travel immunizations Home infusion therapy 70% of R&C; deductible applies (pre-authorization 100% of allowed amount for services through Johns Hopkins Home Care Group (preauthorization Outpatient infusion therapy E00006, E00007, E00161 Page 2 of 6
3 Injections Laboratory Mental Health & Substance Abuse Services Methadone Treatment Nutritional Counseling Injections Materials and serum 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 $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount allowed amount; deductible waived (pre-authorization applies (pre-authorization allowed amount (pre-authorization $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C, deductible applies $10 co-pay, then 100% of allowed amount $10 co-pay, then 100% of allowed amount; deductible waived 70% of R&C, deductible applies $10 co-pay, then 100% of allowed amount allowed amount; deductible waived (pre-authorization applies (pre-authorization allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay per day, then 100% of allowed amount; deductible waived $10 co-pay, then 100% of allowed amount; deductible waived (pre-authorization $10 co-pay; then 100% allowed amount; deductible waived (pre-authorization $30 co-pay for office visit; deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C, deductible applies (limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized) $10 co-pay per day, then 100% of allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount (pre-authorization $10 co-pay per day, then 100% of allowed amount $10 co-pay, then 100% of allowed amount (pre-authorization $10 co-pay; then 100% allowed amount; (preauthorization $15 co-pay, then 100% of allowed amount (limited to 6 visits per plan year for all networks combined; additional visits must be pre-authorized) E00006, E00007, E00161 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. Designated Medical PCP: $10 co-pay; deductible waived; Non-Designated Medical PCP: $20 co-pay; deductible waived Designated Medical PCP: $10 co-pay; deductible waived; Non-Designated Medical PCP: $20 co-pay; deductible waived 70% of R&C; deductible applies 70% of R&C; deductible applies Designated Medical PCP: $10 co-pay; Non- Designated Medical PCP: $20 co-pay Designated Medical PCP: $10 co-pay; Non- Designated Medical PCP: $20 co-pay GYN PCPs: $10 co-pay; deductible waived 70% of R&C; deductible applies GYN PCPs: $10 co-pay $30 co-pay for office visit; eductible applies then 100% of allowed amount; deductible applies 70% of R&C; deductible applies $30 co-pay, then 100% of allowed amount Routine hearing exams Private Duty Nursing Private Duty Nursing Not Covered Not Covered Not Covered Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound 90% of allowed amount; deductible applies 70% of R&C; deductible applies $50 co-pay, then 100% of allowed amount 90% of allowed amount; deductible applies 70% of R&C; deductible applies $10 co-pay, then 100% of allowed amount E00006, E00007, E00161 Page 4 of 6
5 Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment Covered at Johns Hopkins Fertility Center only Covered at Johns Hopkins Fertility Center only 100% of allowed amount after separate $1000 lifetime deductible (deductible applies to services attached to the IVF authorization for treatment; deductible does not apply to testing; pre-authorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and X- rays, in-vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum, all services provided at Johns Hopkins Fertility Center only; member must be enrolled in the EHP Plan for one year before beginning infertility treatment) Birthing centers 100% of allowed amount; deductible applies 70% of R&C; deductible applies Not Available Birthing centers (professional Inpatient maternity care and delivery; newborn nursery care; NICU Inpatient maternity care and delivery; newborn nursery care; NICU $150 co-pay per admission, then 90% of allowed amount; deductible waived(pre-authorization applies (pre-authorization allowed amount (pre-authorization 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 Outpatient surgery (including Inpatient surgery Inpatient surgery (professional Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only Covered at Johns Hopkins Bayview Medical Center & Sibley Memorial Hospital only; $150 Inpatient facility co-pay, then 100% of allowed amount for Professional fees (preauthorization $150 co-pay per admission, then 90% of allowed amount; deductible waived (pre-authorization $300 co-pay per admission, then 90% of allowed amount; deductible applies (pre-authorization allowed amount; (pre-authorization E00006, E00007, E00161 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) Pulmonary rehabilitation Cardiac rehabilitation 90% of allowed amount; deductible applies (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 90% of allowed amount; deductible applies (30 visits per year maximum for all networks combined; pre-authorization 90% of allowed amount, deductible applies (pre-authorization 90% of allowed amount, deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) 70% of R&C; deductible applies (30 visits per year maximum for all networks combined; pre-authorization 70% of R&C; deductible applies (pre-authorization 70% of R&C; deductible applies (pre-authorization $10 co-pay, then 100% of allowed amount (pre-authorization $10 co-pay, then 100% of allowed amount (60 visits per year maximum for all networks combined; PT/OT pre-authorization required for visits 13-60) $10 co-pay, then 100% of allowed amount (30 visits per year maximum for all networks combined; pre-authorization Vision therapy Not Covered Not Covered Not Covered Physician visit $25 co-pay; deductible waived 70% of R&C; deductible applies $25 co-pay Diagnostic services and treatment E00006, E00007, E00161 Page 6 of 6
Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) JHH/JHHSC Non-Union and Union Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Preferred Network Provider EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined with EHP Network)
More informationMedical PPO Plan Schedule of Benefits (Effective January 01, 2019) Bayview Non-Union and Union Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Individual Family Individual Family Hopkins Preferred Network Provider EHP Network Provider Out of Network Provider $150 (under $50K) / $200
More informationMedical EPO Plan Schedule of Benefits (Effective January 01, 2019) Howard County General Hospital/TCAS Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Affiliated Facility Network (facility charges only) EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined
More informationStandard Option Medical Schedule of Benefits (Effective January 01, 2018) Suburban Hospital Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Suburban Hospital (facility charges only) Individual $400 $750 $0 Family $800 $1500 $0 Individual
More informationMedical Schedule of Benefits (Effective January 01, December 31, 2017) Johns Hopkins University Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $250 $500 Family $750 $1500 Individual $2000 $4000 Family $6000 $12000 Unlimited Acupuncture
More informationStandard Option Medical Schedule of Benefits (Effective January 01, 2017) Suburban Hospital Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Suburban Hospital (facility charges only) Individual $400 $750 $0 Family $800 $1500 $0 Individual
More informationMedical Schedule of Benefits (Effective July 01, June 30, 2018) Johns Hopkins Student Health Program
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $150 $150 Family $450 $450 Individual $3000 $3000 Family $9000 $9000 Unlimited Acupuncture
More informationMedical Schedule of Benefits (Effective July 01, June 30, 2019) Johns Hopkins Student Health Program
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum EHP Network Provider Out of Network Provider Individual $150 $150 Family $450 $450 Individual $3000 $3000 Family $9000 $9000 Unlimited Acupuncture
More informationENROLLMENT APPLICATION
ENROLLMENT APPLICATION HOW TO ENROLL IN EHP Please detach this page and review these instructions before completing the "Enrollment Application". If you have any questions, please contact an HR Service
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 informationLOCKHEED MARTIN AERONAUTICS COMPANY MARIETTA 2011 IAM NEGOTIATIONS UNDER AGE 65 LM HEALTHWORKS SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Calendar Year Out-of- Pocket Maximum Lifetime Maximum Per Individual Physician Office Visits Primary Care
More informationSCHEDULE 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
More informationQuote Effective: 04/01/ /30/2019 Version Updated: 01/07/2019
Quote Effective: 04/01/2019-06/30/2019 Version Updated: 01/07/2019 Print Package: HIOS ID (Enrollment Code) 78124NY1000265-00 (SON5) Plan Name: Rating Region: Rate Rochester For the Benefits described
More informationPLAN DESIGN AND BENEFITS - IN MANAGED CHOICE POS OPEN ACCESS 90/60/60 $1,000 PREFERRED CARE
PLAN FEATURES NON- Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
More informationSCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN Enhanced Access HMO Applies to Oakland, Johnstown, and Titusville campuses
SCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN Enhanced Access HMO Applies to Oakland, Johnstown, and Titusville campuses This document is called a Schedule of Benefits. It is part of your Certificate
More informationNorth Carolina Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010
PLAN FEATURES [Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for for prescription
More informationCalifornia Small Group MC Aetna Life Insurance Company NETWORK CARE
PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred
More informationLOCKHEED MARTIN AERONAUTICS COMPANY PALMDALE 2011 IAM NEGOTIATIONS ACTIVE EMPLOYEE S LM HEALTHWORKS (PPO) SUMMARY
Annual Deductibles, Out-of-Pocket Maximums, Lifetime Maximum Benefits Calendar Year Deductible Employee Only: $650 Employee +1: $1,300 ($650 per person) Employee +2 or more: $2,000 (with no more than $650
More informationSchedule of Benefits. Plan Information. Member Cost Sharing
Schedule of Benefits Panther Gold Plan - Enhanced Access HMO Applies to Bradford, Johnstown and Greensburg campuses only HMO Deductible: $0 / $0 Coinsurance: 0% Total Annual Out-of-Pocket: $1,800 / $3,600
More informationCalifornia Small Group MC Aetna Life Insurance Company
PLAN FEATURES Deductible (per calendar year) $5,000 Individual $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward
More informationMEMBER COST SHARE. 20% after deductible
PLAN FEATURES Network Not Applicable Primary Care Physician Selection Not Applicable Deductible (per calendar year) $500 Individual (2-member maximum) Unless otherwise indicated, the Deductible must be
More informationAdventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018
Adventist Health System Schedule of Benefits for Adventist Health System Effective January 1, 2018 High Health Plan with Health Savings Account (Health Savings Plan) TIER 1 TIER 2 TIER 3 CALENDAR YEAR
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 informationFor: 80/20 Plan for Retired Employees Over Age 65 and Dependents
Schedule of Benefits Employer: Cornell University ASC: 397366 Issue Date: September 1, 2010 Effective Date: September 1, 2010 Schedule: 11A Booklet Base: 11 For: 80/20 Plan for Retired Employees Over Age
More informationSCHEDULE OF BENEFITS UPMC HEALTH PLAN PANTHER PREMIER PPO
SCHEDULE OF BENEFITS UPMC HEALTH PLAN PANTHER PREMIER PPO This document is called a Schedule of Benefits. It is part of your Certificate of Coverage or your Summary Plan Description. Your Schedule of Benefits
More informationTraditional Choice (Indemnity) (08/12)
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Not Applicable Not Applicable $500 Individual (2-member maximum) Unless otherwise indicated, the Deductible must be
More informationPLAN DESIGN AND BENEFITS - Tx OAMC % 08 PREFERRED CARE
Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 11/01/2008 PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Individual $3,000 3 Individuals per $9,000
More informationBCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
GRPS Simply Blue Option C $500/$1000 deductible, $20, $40, $80 rx Eligible Groups: Support Non Exempt, Exempt/Professional Admin. Western Michigan Health Insurance Pool Group Number: 71565 Package Code(s):
More informationAetna Select Clerical & Technical and Service & Maintenance Employees. Schedule of Benefits
Aetna Select Clerical & Technical and Service & Maintenance Employees Schedule of Benefits If this is an ERISA plan, you have certain rights under this plan. Please contact your employer for additional
More informationThis is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: MSA Contract Number Control Number:: Barnes Group Inc. 397393 842881 Issue Date: February 15, 2017 Effective Date: January 1, 2017 Schedule: 3A Booklet Base: 3 For: Indemnity
More informationWA Bronze PPO Saver /50 (1/14)
PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services, including member cost sharing
More informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This
More informationPLAN DESIGN AND BENEFITS - Tx OAMC 3000 HSA 100% 08 PREFERRED CARE
Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 09/01/2008 PLAN FEATURES NON- Deductible (per calendar year) $3,000 Individual $6,000 Individual $6,000 Family $12,000
More informationAetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: September 29, 2014 Effective Date: January 1, 2014 Schedule: 8A Booklet Base: 8 For: Aetna Choice POS II - Yale Police Benevolent
More informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider. Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance: 0%
Schedule of Benefits UPMC Business Advantage PPO - Premium Network Primary Care Provider: $20 Copayment per visit Specialist: $20 Copayment per visit Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance:
More informationIL Small Group MC Open Access Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- MC $1,500 80/50/50 (04/09)
PLAN FEATURES Deductible (per calendar ) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
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 informationFor: Traditional Choice - Over Age 65 Corning Retirees - Comprehensive Medical Only - MAP Plus Option 1
Schedule of Benefits Employer: ASA: Control: The Dow Chemical Company 783135 865282 Issue Date: March 15, 2017 Effective Date: March 1, 2017 Schedule: 120B Booklet Base: 120 For: Traditional Choice - Over
More informationAll covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the
More informationSummary 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 /
More information$250 per member. All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) OUT-OF- Not Applicable Primary Care Physician Selection Deductible (per calendar year) Not Applicable $250 per member Not Applicable $250 per member
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 informationMember Cost Sharing Participating Provider Non-Participating Provider Annual Deductible Individual $250 $750 Family $750 $2,250
Schedule of Benefits UPMC Business Advantage PPO - Premium Network Deductible: $250 / $750 Coinsurance: 0% Total Annual Out-of-Pocket: $6,350 / $12,700 Primary Care Provider: $20 Copayment per visit Specialist:
More informationThis is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 3A Booklet Base: 3 For: Choice POS II - 1250 Option - Retirees
More informationNETWORK CARE. $4,500 Individual. (2-member maximum)
PLAN FEATURES Network Open Choice PPO Primary Care Physician Selection Deductible (per calendar year) Not Applicable $750 per member Not Applicable $750 per member (2-member maximum) (2-member maximum)
More informationFull 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
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 informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits Panther Basic HSA PPO - Premium Network Deductible: $1,500 / $3,000 Coinsurance: 30% Total Annual Out-of-Pocket: $5,000 / $10,000 Primary Care Provider: 30% after Deductible Specialist:
More informationNETWORK CARE Managed Choice POS (Open Access)
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Managed Choice POS (Open Access) Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
More informationPLAN DESIGN AND BENEFITS MC Open Access Plan 1913
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $1,500 Individual $4,500 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior
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 informationEmergency 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
More informationCOVENTRY HEALTH AND LIFE INSURANCE COMPANY (Maryland) 2751 Centerville Road, Suite 400 Wilmington, DE
COVENTRY HEALTH AND LIFE INSURANCE COMPANY (Maryland) 2751 Centerville Road, Suite 400 Wilmington, DE 19808-1627 PPO SCHEDULE OF BENEFITS 100/80; $100 Combined Deductible This Schedule is part of Your
More informationChoice POS II (Legacy) Faculty, Managerial & Professional, Post Doctoral Associates and Post Doctoral Fellows Employees. Schedule of Benefits 1A
Choice POS II (Legacy) Faculty, Managerial & Professional, Post Doctoral Associates and Post Doctoral Fellows Employees Schedule of Benefits If this is an ERISA plan, you have certain rights under this
More informationST. MARY S HEALTHCARE SYSTEM, INC.-CASE # GA6476 Blue Choice HI PPO Benefit Summary Effective: January 1, 2019
ST. MARY S HEALTHCARE SYSTEM, INC.-CASE # GA6476 Blue Choice HI PPO Benefit Summary Effective: January 1, 2019 All benefits are subject to the calendar year deductible, except those with in-network copayments,
More informationOther Participating UPMC Facilities Level 2 Benefit Period
Schedule of Benefits Advantage Panther Gold Plan - Enhanced Access HMO Applies to Oakland and Titusville campuses HMO Deductible: $0 / $0 Coinsurance: 0% Total Annual Out-of-Pocket: $1,800 / $3,600 Primary
More informationThis is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Rider University ASA: 884014 Issue Date: January 2, 2013 Effective Date: January 1, 2013 Schedule: 1E Booklet Base: 1 For: Choice POS II (Aetna Choice POS II) Safety Net
More informationSimply Blue SM PPO Plan $1000 LG Medical Coverage Benefits-at-a-Glance
Simply Blue SM PPO Plan $1000 LG Medical Coverage Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only a general overview of your benefits.
More informationCONNECTICUT 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:
More informationFor more information on your plan, please refer to the final page of this document.
Schedule of Benefits Panther Blue - General Student Health Plan PPO - Premium Network Deductible: $250 / $500 Coinsurance: 10% Total Annual Out-of-Pocket: $4,200 / $8,400 This document is your Schedule
More informationJHHSC/JHH EHP Medical Plan Coverage Period: 01/01/ /31/2014
JHHSC/JHH EHP Medical Plan Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO This is only a summary.
More informationAll covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Deductible (per calendar year) Not Applicable $500 per member Not Applicable $500 per member (2-member maximum) (2-member
More informationNETWORK CARE. $4,500 (2-member maximum)
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $4,500 (2-member maximum) Unless otherwise indicated, the Deductible
More informationNETWORK CARE. $250 per member (2-member maximum)
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the
More informationSCHEDULE OF BENEFITS UPMC HEALTH PLAN - POINT PARK UNIVERSITY STUDENT HEALTH PLAN
SCHEDULE OF BENEFITS UPMC HEALTH PLAN - POINT PARK UNIVERSITY STUDENT HEALTH PLAN Covered Services, which may be subject to a Deductible and Coinsurance, are provided during a Benefit Period as outlined
More informationNETWORK CARE. $3,500 Individual $7,000 Family
PLAN FEATURES Network Primary Care Physician Selection Deductible (per calendar year) Managed Choice POS (Open Access) OUT-OF- $2,000 Individual $4,000 Family Unless otherwise indicated, the Deductible
More informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider Benefit Period
Schedule of Benefits Duquesne University HSA PPO - Premium Network Deductible: $1,500 / $3,000 Coinsurance: 10% Total Annual Out-of-Pocket: $4,500 / $6,850 Primary Care Provider: 10% after Deductible Specialist:
More informationGroup Name. South Seneca School District
Group Name South Seneca School District Excellus BlueCross BlueShield makes finding the information and support you need easier resources, savings, and tools are available online 24/7. Find a doctor or
More informationCalendar 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
More information$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
More informationOPERATING ENGINEERS LOCAL324 Community Blue PPO Effective Date: 01/01/2016
OPERATING ENGINEERS LOCAL324 Community Blue PPO 007005154 Effective Date: 01/01/2016 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract.
More informationThis is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Apria Healthcare Group, Inc. ASA: 476706 Issue Date: May 7, 2013 Effective Date: January 1, 2013 Schedule: 2A Booklet Base: 2 For: Choice POS II High Deductible Health Plan-Apria
More informationNETWORK 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
More informationFull PPO Savings Two-Tier Embedded Deductible 2250/2700/4500 Effective January 1, 2019
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
More informationEffective: July 1, Highlights: A description of the prescription drug coverage is provided separately. Participating Providers 1
High Desert & Inland Trust Custom PPO 3 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: July 1, 2016 THIS MATRIX IS
More informationBCBSM 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): 016 Section Code(s): 1010, 1110 PPO Select 4, RX1, Hearing Effective Date: 01/01/2018 Benefits-at-a-glance This is intended as
More informationSchedule of Benefits. Plan Information Participating Provider Non-Participating Provider
Schedule of Benefits Panther Advocate - HealthyU HIA PPO - Premium Network Deductible: $500 / $1,000 Coinsurance: 10% Total Annual Out-of-Pocket: $2,000 / $4,000 Primary Care Provider: 10% after Deductible
More informationThis is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information.
Schedule of Benefits Employer: Adobe Systems Incorporated MSA: 660819 Issue Date: January 1, 2018 Effective Date: January 1, 2018 Schedule: 2B Booklet Base: 2 For: Aetna Choice POS II HDHP - HealthSave
More informationMEDICAL SCHEDULE OF BENEFITS COPAY GOLD
NON- LIFETIME MAXIMUM BENEFIT Unlimited CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes Deductible, Coinsurance, Copays and Precertification
More informationBCBSM 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
More informationNot 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)
More informationBenefits Summary SelectHC IV
Benefits Summary SelectHC IV An Embedded Deductible, High Deductible Health Plan (HDHP) This chart only summarizes covered benefits. Please refer to the Policy for coverage details including exclusions
More informationMEDICAL SCHEDULE OF BENEFITS COPAY GOLD
LIFETIME MAXIMUM BENEFIT CALENDAR YEAR MAXIMUM BENEFIT CALENDAR YEAR DEDUCTIBLE Single Family CALENDAR YEAR OUT-OF-POCKET MAXIMUM (includes medical Deductible, medical Coinsurance, medical Copays and Precertification
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 informationLee s Summit School District
Plan Type Plan Description (Visit our website at www.bluekc.com to receive a complete listing of network hospitals and physicians) Lee s Summit School District Effective Date: 1/1/16 Health Benefit Plan
More informationAetna Select Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Plan Maximum Out of Pocket Limit excludes precertification penalties.
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: July 25, 2016 Effective Date: January 1, 2016 Schedule: 12D Booklet Base: 12 For: Aetna Select - Security Staff (Outside CT) Electing
More informationBenefit modifications for members with Full PPO /60
An independent licensee of the Blue Shield Association A17436 (01/2017) Benefit modifications for members with Full PPO 250 80/60 Effective January 1, 2017 The Full PPO 250 80/60 plan name will be changed
More informationAnnual deductibles and maximums In-network Out-of-network Lifetime maximum
SUMMARY OF BENEFITS City of Richmond & Richmond Public Schools (Plan B) Connecticut General Life Insurance Co. Annual deductibles and maximums Lifetime maximum Unlimited per individual Pre-Existing Condition
More informationSimply Blue SM HSA PPO Plan 2000/0% LG Medical Coverage with Prescription Drugs Benefits-at-a-Glance
Simply Blue SM HSA PPO Plan 2000/0% LG Medical Coverage with Prescription Drugs Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only
More informationI. PLAN DESCRIPTIONS. A. POS Point of Service
I. PLAN DESCRIPTIONS A. POS Point of Service The Partnership Plan offers a single point of service plan to provide healthcare services both within and outside a defined network of Providers. No referrals
More informationPLAN DESIGN AND BENEFITS - PA POS COST-SHARING 3.4 ($1,500 DED) PARTICIPATING PROVIDERS. $1,500 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $3,000 Individual $6,000 Family 50% $6,000 Individual $12,000 Family Amounts over the Recognized Charge, failure to pre-certification
More informationBCBSM 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
More informationBCBSM 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
More information$4,800 $9,600 Maximum Lifetime Benefit
PPO Schedule of PPO Medical C & A Industries, Inc. Plan Effective Date: January 1, 2019 In-Network Out-of-Network** Benefit Year means a calendar year, which is the period of twelve (12) consecutive months
More informationPLAN DESIGN AND BENEFITS - PA POS COST-SHARING NO-REFERRAL 4.4 ($2,000 DED) $2,000 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $4,000 Individual $8,000 Family 50% $8,000 Individual $16,000 Family Amounts over the Recognized Charge, failure to pre-certification
More informationHealthy New York Summary of Benefits
Healthy New York Summary of Benefits Services Hospital Services Skilled Nursing Facility Surgery Anesthesia Diagnostic X-ray Diagnostic Laboratory and Pathology Chemotherapy Radiation Therapy Surgical
More informationSchedule of Benefits. Plan Information. Primary Care Provider: $10 Copayment per visit
Schedule of Benefits PPO IA - Premium Network Deductible: $500 / $1,000 Coinsurance: 0% Total Annual Out-of-Pocket: $6,450 / $12,900 Primary Care : $10 Copayment per visit Specialist: $30 Copayment per
More informationIndividual Deductible* $950 $950. Family Deductible* $1,900 $1,900
Schedule of Benefits Employer: The Vanguard Group, Inc. ASA: 697478-A Issue Date: January 22, 2018 Effective Date: January 1, 2018 Schedule: 3B Booklet Base: 3 For: Choice POS II - $950 Option - Retirees
More informationSchedule of Benefits Aetna Consumer Directed Health Plan (CDHP) January 1, 2018
Schedule of Benefits Aetna Consumer Directed Health Plan (CDHP) January 1, 2018 This is an ERISA plan, and you have certain rights under this plan. Please contact the Human Resources Benefits Team for
More informationBenefits-at-a-Glance for MSU Student Health Plan
Benefits-at-a-Glance for MSU Student Health Plan 2016-2017 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations
More information