STUDENT EDUCATIONAL BENEFIT TRUST (SEBT) DETROIT ROAD, WESTLAKE OHIO 44145, 1 (877)
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- Noreen Cobb
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3 Plan A Prepaid SHC Plan (Excess Plan) Plan B International Plan Plan C Domestic Plan Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Plan Type Eligible Student Population (Mandatory) Eligible Student Populaiton (Voluntary) Lifetime Maximum per Person Excess Policy Students with other Coverage Excess Policy Students without other Coverage $175,000 Primary (Comprehensive) Students without other Coverage Combined Lifetime Maximum for MHSA Annual Maximum per Year $2,500 Annual Deductible per Year $300 $600 $1,000 $300 $600 $1,000 $300 $600 $1,000 Deductible per Injury / Accident per Year PreExisting Conditions Student Health Services (Virtual Medical Office) Domestic Waived for all Domestic Students Waived for all Domestic Students Waived for all Domestic Students International 12/6 Waived with Creditable Coverage 12/6 Waived with Creditable Coverage 12/6 Waived with Creditable Coverage Individual Family Individual Family Individual Maximum Out of Pocket NA NA NA $6, $12, $6, $12, Student Health Services (Virtual Medical Office) Student Health Services Student Health Services Student Health Services Enrolled Students Doctor 100% NA NA 100% NA NA 100% NA NA Enrolled Students Extended 100% NA NA 100% NA NA 100% NA NA Enrolled Student Nurse 100% NA NA 100% NA NA 100% NA NA 24/7 Telephonic MD Service (SEBT Contract) 100% NA NA 100% NA NA 100% NA NA Wellness and Preventive (HCR) 100% NA NA 100% NA NA 100% NA NA Lab and XRays 100% Paid where speciman or xray is taken 100% Paid where speciman or xray is taken 100% Paid where speciman or xray is taken Perexisting Condition Limitations Waived for all students and all services within SHS or VMO Waived for all students and all services within SHS or VMO Waived for all students and all services within SHS or VMO Referral Requirement YES To Access the Group Specific Network YES To Access the Group Specific Network YES To Access the Group Specific Network PreCertification Requirement Yes NA Yes NA Yes NA Local (Urgent Care) 100% NA NA 100% NA NA 100% NA NA Inpatient Hospital Room and Board (HRB or BASIC) 90% 80% 90% 80% Intensive Care 90% 80% 90% 80% Hospital Miscellaneous Expenses (HME) 90% 80% 90% 80% Hosptial Based s Paid per the setting of the Facility Paid per the setting of the Facility Medical Emergency Expense $100 Copayment $100 then 80% $100 then 80% $100 Copayment $100 then 80% $100 then 80% Hospital Visit 90% 80% 90% 80% Surgical Expense 90% 80% 90% 80% Anesthesia Not Covered under this Plan Look to Primary 90% 80% 90% 80% Assistant Surgeon 90% 80% 90% 80% Registered Nurse's Services 90% 80% 90% 80% Skilled Nursing 90% 80% 90% 80% Limited: 90 Days/Benefit Period Limited: 90 Days/Benefit Period Transplant Services 90% 80% 90% 80% Physiotherapy 90% 80% 90% 80% Psychotherapy 90% 80% 90% 80% STUDENT EDUCATIONAL BENEFIT TRUST (SEBT) DETROIT ROAD, WESTLAKE OHIO 44145, 1 (877)
4 Outpatient Pharmacy Benefits Additional Benefits Plan A Prepaid SHC Plan (Excess Plan) Plan B International Plan Plan C Domestic Plan Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Outpatient Limit per Year $1,500 Deductible Surgical Expense & Day Surgery Misc. 90% 80% 90% 80% 90% 80% Outpatient 's Visit (OPV) 90% 80% 90% 80% 90% 80% Injections (OPV) 90% 80% 90% 80% 90% 80% Urgent Care Expenses 90% 80% 90% 80% 90% 80% 24/7 Telephonic MD Virtual Medical Office 100% 100% 100% Physiotherapy 90% 125 Visits/ 80% 125 Visits/ 90% 125 Visits/ 80% 125 Visits/ 90% 125 Visits/ 80% 125 Visits/ Chiropractic 90% 125 Visits/ 80% 125 Visits/ 90% 125 Visits/ 80% 125 Visits/ 90% 125 Visits/ 80% 125 Visits/ Assistant Surgeon 90% 80% 90% 80% 90% 80% Laboratory & XRay Expense 90% 80% 90% 80% 90% 80% Test & Procedures 90% 80% 90% 80% 90% 80% Injections 90% 80% 90% 80% 90% 80% Preventive & Wellness Benefits (HCR) 100% to $450, 80% 100% 80% 100% 80% 100% with referral from SHS 100% with referral from SHS 100% with referral from SHS OBGYN (Annual Exam) 100% 80% 100% 80% 100% 80% Psychotherapy 90% 80% 90% 80% 90% 80% Prescription Maximum Pharmacy Supply Limit Deductible $350 per Year UA Health Center Pharmacy UA Health Center UA Health Center InNetwork OutofNetwork InNetwork OutofNetwork & SEBTRx Pharmacy & SEBTRx Pharmacy & SEBTRx InNetwork OutofNetwork Tier 1 $5 $5 + 20% $5 + 40% $5 $5 + 20% $5 + 40% $5 $5 + 20% $5 + 40% Tier 2 $20 $20 +20% $ % $20 $20 +20% $ % $20 $20 +20% $ % Tier 3 $30 $30+20% $ % $30 $30+20% $ % $30 $30+20% $ % Contraceptives 100% 100% 100% 100% 100% 100% 100% 100% 100% 90 Day Maintenance Supply Deductible Durable Medical Equipment 80% 80% 80% 80% 80% 80% 80% 80% Consultant Fees 80% 80% 80% 80% 80% 80% NeedleStick Benefit Infertility (Counseling, Testing & Treatment) Transexualism/Gender Identity Club Sports Intramural Sports ICS Sports Treatment for TMJ Not Covered Look to Primary Paid as Accident $500 Max Paid as Accident $500 Max Paid as Accident $2500 Max Not Covered Look to Primary 80% 80% upto $750, 80% upto $750, Paid as Accident $500 Max Paid as Accident $500 Max Paid as Accident $2500 Max 80% 80% 90% upto $750, 90% upto $750, Paid as Accident $500 Max Paid as Accident $500 Max Paid as Accident $2500 Max 80% Ambulance 80% upto $750, 80% 80% 80% 80% 80% 80% Dental Treatment, injury to sound teeth only Term Life Insurance Accidental Death & Dismemberment Paid as Accident $250 Max Paid as Accident Paid as Accident $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 STUDENT EDUCATIONAL BENEFIT TRUST (SEBT) DETROIT ROAD, WESTLAKE OHIO 44145, 1 (877)
5 International Services (Cigna Global) Medical Evacuation /Repatriation Political and Natural Disaster Evacuation/Repratriation (HXGlobal) Contract Year Medical Benefit Maximum Contract Year Deductible Out of Pocket Coinsurance Maximum Prescriptions Drug Replacement Services Emergency Dental (International) Personal Deviation Inpatient CignaLinks Outpatient CignaLinks Additional Services CignaLinks Precertification (US) Precertification (International) Cigna Envoy Worldwide, Screened Practitioner Network Direct Pay ICS Sports Blanket Policy $90,0000 $2,500 Deductible 100% Consurance $90,000 Max Benefit Per Accident Annual Cost Plan A Prepaid SHC Plan (Excess Plan) Plan B International Plan Plan C Domestic Plan Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Group Specific Network InNetwork Out ofnetwork Stand Alone is Available This is an optional blanket policy that would be paid for by the University, but is intended to cover upto $90,000 $98,940 Limited to $100,000 Limited to $100,000 $100,000 $100,000 $250 $250 80/20 80/20 24/7/365 24/7/365 SEBT SEBT CIGNA GLOBAL CIGNA GLOBAL STUDENT EDUCATIONAL BENEFIT TRUST (SEBT) DETROIT ROAD, WESTLAKE OHIO 44145, 1 (877)
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.calcpahealth.com or by calling 1-877-480-7923. Important
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SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Cornerstone Systems, Inc. Open Access Plus General Services In-network Out-of-network Primary care physician You pay $30 copay per visit Physician
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-855-603-7982. Important Questions
Health Insurance Matrix 01/01/18-12/31/18
Employee Contributions Family Monthly : $143.68 Bi-Weekly : $71.84 Monthly : $331.77 Bi-Weekly : $165.88 Monthly : $488.41 Bi-Weekly : $244.20 Monthly : $835.22 Bi-Weekly : $417.61 Employee Contributions
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: Premium Plan This is only a summary. If you want more detail about your coverage and costs, you
Quote 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
National Guardian Life Insurance Company: Maine College of Art Student Health Insurance Plan Coverage Period: 09/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Summary of Benefits and Coverage The benefit plan year for ALL benefits begins March 1, 2018 and continues through February 28, 2019.
Summary of Benefits and Coverage The benefit plan year for ALL benefits begins March 1, 2018 and continues through February 28, 2019. The following information is not intended to be a detailed description
You 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
Medical Plan Summary: PPO Core Plan
Medical Plan Summary: PPO Core Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation
Anthem Blue Cross: Anthem Silver DirectAccess, a Multi-State Plan 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/ca or by calling 1-855-333-5730. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.summacare.com or by calling 1-800-996-8701. Important
What 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 &
Sigma-Aldrich Corporation Healthcare Plans MEDIUM Option Coverage Period: 01/01/ /31/2016 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.mysialbenefits.com or by calling 1-877-335-7515, option
National Guardian Life Insurance Company: Colby College Student Health Insurance Plan Coverage Period: 08/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
In-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
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.arcsvs.com or by calling 1-877-309-2955. Important Questions
Nationwide Life Insurance Co.: Platinum Plan - Ithaca College Coverage Period: 8/10/15-8/9/16
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
Senior Care Network: Blue Access PPO and Blue Access Choice PPO Coverage Period: 01/01/ /31/2016
Senior Care Network: Blue Access PPO and Blue Access Choice PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual/Family
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
: Samford University Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage For: Individual + Family Plan Type: PPO This is only