Distinctive Care SCHEDULE OF BENEFITS Participating Provider Covered Person pays:
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1 Benefit Local Office Visits/Physician Consultation (per visit/occurrence) Primary Care Specialist Walk-in Clinics Visit Distinctive Care Participating Provider Covered Person pays: $35 Co-payment $50 Co-payment Covered Person pays: $30 Co-payment per visit Lab, Prescription, Procedure 20% Co-insurance up to Out-of-Pocket; Prescription Laboratory Diagnostic Ultra Sound CAT Scan MRI Scan PET Scan Medical Supplies Pre-Certification required Covered Person pays Deductible plus 20% Co-insurance Preventive Care Newborn Care (Initial examination after birth and nursery) Newborn must be enrolled within 31 days of birth. Coverage begins from day 1 Immunization Colina pays 100% Routine Immunization for dependent children Covered at 100% reasonable and customary charges
2 Preventive Care Distinctive Care Please contact Colina for benefits Annual Health Check Mammogram one per calendar year (for insured females age 35 years and older) Pap Smear one per calendar year (for insured females age 18 years and older) Annual Prostate Exam one per calendar year (for insured males age 35 years and older) PSA Test one per calendar year (for insured males age 35 years and older) Other Test Comprehensive Metabolic Panel, CBC, FBS, SMAC- 25, Lipid In-office Surgery Minimum amount starts at $ per individual annually In-Office Surgical Expenses In-office Anesthesia Pre-certification required for procedures $ and above In-Office Anesthesia All payments are based upon Reasonable and Customary charges. Non pre-certification requires Covered Person to pay deductible plus 50% Co-insurance of Reasonable and Customary charges, subject to the respective benefit maximums. Pre-Certification is required for the following: - Hospitalizations - Out-Patient surgical procedures (whether provided at a hospital, ambulatory surgical Centre or a physician s office) - Magnetic Resonance Imaging services - Durable Medical Equipment - Rehabilitation/ Skilled Nursing Facility Confinements - Home Health Services - Human Organ Transplants - In-Patient Treatment
3 - Behavioral Health Disorders - Air Transportation (ambulance or commercial airfare) - Outside The Bahamas daily allowances - Return of deceased/repatriation Exclusions No benefits are payable for: 1. The evaluation of routine and other treatment of learning disabilities; 2. Pregnancies whose conception occurs prior to the Effective Date; 3. Industrial Accidents 4. Treatment for pre-existing ailments occurring within the first 12 months of the policy 5. Self inflicted injury, suicide or attempted suicide 6. Non-medical equipment 7. Maximum benefit limits 8. Expenses incurred after termination date 9. Treatment by a close relative who or an occupant living in the covered person s home. 10. Recreational or educational therapy 11. Radioactive contamination 12. Treatment or injury arising from war or war related activity, voluntary participation in assaults, civil commotions, conspiracies, riots, public disturbances, high risk sports (but not limited to, parachuting, skydiving, water skiing, diving, mountain climbing, bungee jumping, motor vehicle or powerboat racing, hand gliding, ballooning and reckless endangerment of any form 13. The following drugs, medicines or supplies, even if prescribed by a Physician: a. Vitamins, dietary supplements, appetite suppressants, hair regenerative or cosmetics, health and beauty aids, nicorette gum or smoking suppressants; b. Experimental or Investigative drugs, medicines, or supplies; c. OTC drugs and medication; d. Contraceptive drugs or devices, prescription or otherwise, unless prescribed for other than
4 contraceptive purposes to treat a medically diagnosed condition; e. Drugs prescribed for non-medical conditions, or drugs for conditions which are not covered under this Policy; 14. In addition to the above, the following out-patient drugs are not covered: (all of the below) a. Accutane (Isotretinoin); b. All forms of Retin (Retinoid Acid); c. AIDS specific drugs not yet approved for use and still in the experimental stage; d. Progesterone suppositories (except in complications of pregnancy); e. Fertility drugs; f. Immunosuppressants (unless under the control of a Physician); g. Monoxidil for topical use. 15. Infertility test, treatment and related procedures, including hormonal treatment, pregnancies and new born children born as a result of fertility treatment. 16. Weight loss, weight control programs including surgical intervention, unless medically necessary to treat Endogenous Morbid Obesity diagnosed by a Physician. 17. Personal or comfort items such as radio, television, barber or beauty services; 18. Charges by any provider of care or service who or which is not duly licensed or certified to render the treatment or services provided; or any service or supply not prescribed by a qualified Physician; 19. Maternity charges for dependent children and unenrolled spouses. 20. Any service or supply not provided in accordance with accepted medical or professional standards of practice; or which is Experimental or Investigative in nature, or is research oriented; 21. Any service or supply not specifically listed as a benefit under this Policy; 22. Weekend charges incurred for Hospital Confinements that start on Friday, Saturday or Sunday, unless: a. the attending Physician certifies that such weekend admission is Medically Necessary; or b. such weekend Hospital Confinement is in connection with a surgery scheduled for the day that next follows the date of admission (Saturday, Sunday or Monday);
5 23. Any Charges for elective abortions; 24. Any expense, charge or fee that exceeds the Usual Customary and Reasonable amount.
SHAPE A SCHEDULE OF BENEFITS
Benefit Local Office Visits/Physician Consultation (per visit/occurrence) Walk-in Clinics Primary Care Specialist SHAPE A Participating Provider Covered Person pays: $25 Co-payment $35 Co-payment $50 Co-payment
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Duke University Scholars Program 2015 2016 Blanket Student Accident and Sickness Insurance 100 Matsonford Road One Radnor Corporate Center Suite 100 Radnor, PA 19087 USA Call: 610.254.8700 Fax: 610.293.3529
BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
Western Michigan Health Insurance Pool Group Number: 71565 Package Code(s): 040, 041 Section Code(s): 3000, 3100 PPO - Flexible Blue 3, RX7 Effective Date: 01/01/2018 Benefits-at-a-glance This is intended
BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
Western Michigan Health Insurance Pool Group Number: 71565 Package Code(s): 036, 037 Section Code(s): 3000, 3100, 3300, 3400 PPO - Flexible Blue 2, RX6 Effective Date: 01/01/2018 -at-a-glance This is intended
$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
PLAN DESIGN & BENEFITS
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $250 Individual $500 Individual $500 Family $1,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
BCBSM 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):
PLAN DESIGN & BENEFITS HDHP Standard ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per year) $1,750 Individual $3,500 Individual $3,500 Family $7,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
Qualified High Deductible Health Plan PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $6,600 Individual $20,000 Individual $13,200 Family $40,000 Family All covered expenses accumulate simultaneously toward both the