Traditional Plan Inside UHACO Effective January 1, You pay: $600 $1,200 $2,200
|
|
- Flora Matthews
- 5 years ago
- Views:
Transcription
1 Traditional Plan Inside UHACO Effective January 1, 2016 Calendar Year Deductible 1 Per Individual Per Family Member s Coinsurance 2 Out-of-Pocket Maximum 4 (includes deductible, coinsurance and copayments) Per Individual Per Family Maximum Age for Eligible Children Tier 1 (UHACO Network) $600 $1,200 Tier 3 (Out-of-Network) $2,000 $4,000 15% after deductible 50% of R&C 3 after deductible $2,200 $11,500 $4,400 $23,000 Age 26 (Eligible Children are covered until the end of the month the child reaches age 26) Covered Services Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Preventive Services (Note: only available when accessed through a PCP or OB/GYN) General Physical Exam (includes routine EKG, complete blood count, comprehensive metabolic panel, 0% no deductible 50% of R&C after deductible urinalysis) Routine Preventive Screenings (Cholesterol test, Bone Density Test, Pelvic Exam, Pap Test, Prostate Specific Antigen Test, Routine Colorectal Cancer Screening, Tuberculin Skin, TSH) Routine Mammogram Well Baby/Well Child Care Visits Immunizations 1 One person on the family plan only has to meet the individual amount listed. Co-payments do not apply to the Deductible. 2 Coinsurance is the percentage share of costs you pay after you meet the Deductible. 3 You will be responsible for paying any amount in excess of R&C in addition to the Deductible and Coinsurance. 4 Annual out-of-pocket is the maximum you pay between the deductible, coinsurance and co-payments before expenses are paid at 100% in-network. One person on the family plan only has to meet the individual amount listed. This includes deductibles and coinsurance, co-payments and excludes Prescription Copayments and Coinsurance, Infertility treatment coinsurance and amounts over Reasonable and Customary Charges. Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.
2 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Routine Vision Exam (One exam per benefit period) 0% no deductible 0% no deductible 5 Emergency/Urgent Care Services Emergency use of the Emergency Room Emergency Room Physicians Urgent Care Services $250 Co-payment per visit (waived if admitted/observation) $250 Co-payment then 0% of R&C per visit (waived if admitted/observation) 0% no deductible 0% of R&C no deductible $40 Co-payment per visit 50% of R&C after deductible Medical Services Primary Care Office Visits Additional Services Performed during the PCP Visit Specialist Office Visits Additional Services Performed during the Specialist Visit Inpatient Physician Services Outpatient Physician Services Diagnostic X-ray & Laboratory Services $25 Co-payment per visit 50% of R&C after deductible Facility Services Inpatient Services Outpatient Services Outpatient Surgery Center Other Services Ambulance Transport (for emergent medical transport and medically necessary non-emergent transport) 0% no deductible 5 You will be responsible for paying any amount in excess of 100% of R&C in addition to the deductible and coinsurance.
3 Traditional Plan Inside UHACO Effective January 1, 2016 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Bariatric Surgery (limited to $10,000/lifetime) Chiropractic Services (limited to 20 visits per benefit period) Additional Services Performed during the Chiropractic visit Durable Medical Equipment Home Health Care (limited to 50 visits per benefit period; includes RN, physical, occupational and speech therapy) Hospice Services Inpatient Rehabilitation (limited to 60 days per benefit period) Rehabilitative Services (Physical//Occupational therapy limited to 30 visits per benefit period combined; Speech therapy limited to 30 visits per benefit period) Skilled Care Facility (limited to 90 days per benefit period) Transplants $25 Co-payment per visit 50% of R&C after deductible Mental Health and Substance Abuse/Alcohol Abuse Services Inpatient Outpatient Partial Hospitalization, Intensive Outpatient Services and Ambulatory Detoxification (see SPD for details) Residential Not Covered Reproductive Care Services Pre and Postpartum Maternity Care Visits $25 Co-payment (initial visit only) 50% of R&C after deductible Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.
4 Covered Services Tier 1 (UHACO Network) Tier 3 (Out-of-Network) Pre and Postpartum Maternity Services Inpatient Delivery Charges Childbirth Education classes Contraceptive Implants and Devices Infertility Diagnostics Infertility Treatments (limited to $10,000/lifetime; limited to MacDonald and IVF Program) Hearing Aid Services Hearing Aid Evaluation Hearing Aid Test Hearing Aid (limited to one per ear every four benefit periods) Cochlear Implants Not Covered 50% after deductible Not Covered $25 Co-payment per visit 50% of R&C after deductible
5 Traditional Plan Inside UHACO Effective January 1, 2016 Prescription Drug Services (Administered by CVS Caremark) Calendar Year Deductible None Prescription Drug Out-of-Pocket Maximum Per Individual Per Family Network Retail (30 day supply/prescription) Network Mail Order or retail & CVS/ pharmacy (90 day supply/prescription) Non Network Retail Smoking Cessation Drugs Immunizations Infertility Drugs Diabetic Supplies ( 200 meter strips per individual per month ; additional meter strips covered as needed with prior authorization) Generic Drug Program Prior Authorization $2,500 $5,000 Generic Formulary Brand Name Non Formulary Brand Name Prescription Prescription 30% 50% $15 Co-payment* $30 minimum* $70 minimum* $75 maximum $200maximum 20% 50% $30 Co-payment* $60 minimum* $150 minimum* $150 maximum $400 maximum Not Covered Covered 100% for approved dosage levels for tobacco cessation treatment for the following: Buproprion (HCL Tab SR 12HR 150 MG), Chantix, generic nicotine patches, gum, or lozenges. Covered at 100% shingles for members 50 years of age and older; flu and pneumonia immunization only when administered by a pharmacist. 50% Paid by Member up to a lifetime maximum benefit of $5,000. This coinsurance does count toward the annual maximum out-of-pocket limit. Meter strips, lancets, syringes, urine test strips and one blood glucose meter per year will be covered at one Generic copayment per Prescription. Generic Drugs will be dispensed whenever permitted by state and federal law. If the Member requests a Brand Name Drug when a Generic equivalent is available, the Member will be charged the generic copayment plus the difference in cost between the Brand Name Drug and the Generic Drug. See Step Therapy for information about using a generic drug first before certain brand drugs. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. Prior authorization must be obtained by your physician in order for you to receive benefit for these drugs. Drug classes with Prior Authorization may include but may not be limited to: ADHD (>19y/o), Nacolepsy, Anacolic Steroids, Pain (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys), Testosterone Products, Acne (>35 y/o). Complete benefit descriptions, services requiring Prior Authorization and exclusions are contained in the UH Summary Plan Description (SPD) and any applicable Summary Material Modification. In situations where there are differences between this Schedule of Benefits and the Summary Plan Description, the SPD will govern.
6 Prescription Drug Services (Administered by CVS Caremark) Quantity Limits Certain prescription drugs have specific Quantity Limits per prescription per month. Step Therapy Drug classes with a Quantity Limit include but may not be limited to: Antiemetic (nausea), Antimigraine Influenza (Tamiflu, Relenza). Certain prescriptions drugs require Step Therapy, which is a process where you may be required to first try an alternative therapy before your prescription benefits may be used toward the requested medication. You must first try generic drugs, if available, before using certain brand drugs. Drug classes with Step Therapy include: Solodyn Drug classes with Generic Step Therapy include but may not be limited to: ARB/Combos (blood pressure), bisphosphonates, HMGs (cholesterol), Sleep agents, PPIs (acid reflux), NSAIDs, Nasal Steroids, SSRIs/SNRIs, (depression/pain), Triptans (migraine), Urinary Antispasmodics (overactive bladder), Fibrates (cholesterol), BPH (enlarged prostate), Prostaglandin Analogs (glaucoma), Acne, Asthma/COPD Coverage Exceptions For certain medications covered at zero cost per provisions related to Affordable Care act also known as Health Care Reform (HCR), a member can receive preventive services or a contraceptive product for a $0 member cost share. Medications covered at no copay under HCR include preventive services medications (Aspirin, Folic Acid, Fluoride, Smoking Cessation Drugs, Etc) and contraceptive agents. Specialty Preferred Drug Therapy In select categories of specialty medications (infertility, TNG inhibitors and growth hormones), a member must try a preferred product before having access to a nonpreferred product. Your physician can contact CVS Caremark for coverage of a nonpreferred product should clinical evidence suggest that drug is medically necessary. Contraceptives Contraceptive injectables, oral and patch are covered. Contraceptive implants and devices are covered under the medical benefit. *If the full cost of the drug is less than the minimum, you pay the full cost of the drug. A 90-day supply of maintenance medications may be filled at either mail order or a CVS Caremark retail store.
UNIVERSITY HOSPITALS SCHEDULE OF MEDICAL AND PRESCRIPTION DRUG BENEFITS
Plan Limits 1 Calendar Year Deductible (Does not include copayments) Coinsurance (Paid by Plan) (Amount Plan pays after deductible is met, unless otherwise specified) Calendar Year Maximum Out-of-Pocket
More informationHealth Savings PPO Benefits-at-a-Glance CHE Trinity Health
Health Savings PPO Benefits-at-a-Glance Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Copays/Coinsurance Fixed Dollar Copays Tier 1 Facilities and Aligned Professional
More informationHBS PPO Standard B1 Benefits-at-a-Glance Trinity Health
HBS PPO Standard B1 Benefits-at-a-Glance Trinity Health Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Tier 1 Trinity Health Facilities and Aligned Professional Providers
More informationHBS PPO Enhanced Plan B1 Benefits-at-a-Glance CHE Trinity Health
HBS PPO Enhanced Plan B1 Benefits-at-a-Glance Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Tier 1 Tier 2 Tier 3 PPO In-Network Facility Facilities and Aligned Professional
More informationHealth Savings PPO Benefits-at-a-Glance Trinity Health
Health Savings PPO Benefits-at-a-Glance Trinity Health Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Health Savings PPO seed money Amount prorated based upon date of
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 informationTraditional Plan (Modified) Summary Trinity Health
Traditional Plan (Modified) Summary Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar year $250 per member $500 per family Copays Fixed Dollar Copays $20 copay
More informationTraditional PPO Plan (Modified) Benefits-at-a-Glance Trinity Health
Traditional PPO Plan (Modified) Benefits-at-a-Glance Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar year $250 per member $500 per family Copays Fixed Dollar
More informationHealth Savings Plan Summary Trinity Health
Health Savings Plan Summary Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per $1,500 per member The full family deductible must be met $3,000 per family under a two person
More informationHealth Savings PPO (Modified) Benefits-at-a-Glance Trinity Health
Health Savings PPO (Modified) Benefits-at-a-Glance Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar $1,300 per member The full family deductible must be met under
More informationSCHEDULE OF BENEFITS
SCHEDULE OF BENEFITS To receive the highest level of benefits at the lowest Out-of-Pocket Maximum expense, Covered Services must be provided by PPO Network Providers. When you use other Providers who are
More informationCA HMO Deductible $1,500 70%
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
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 informationPLAN DESIGNS AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC
Aetna Pharmacy Management Custom RX PLAN FEATURES Deductible (per calendar year) $250 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance
More informationEssential Assist w HRA (Modified) Summary Trinity Health
Essential Assist w HRA (Modified) Summary Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar year The full family deductible must be met under a two person or family
More informationPLAN DESIGN & BENEFITS. $100 Individual/$200 Family $500 Individual/$1000 Family
PLAN FEATURES Deductible (per calendar year) Provider None $1000 Individual/$2000 Family Deductible (per calendar year) Facility Level A: Level B: $100 Individual/$200 Family $500 Individual/$1000 Family
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 information2014 Side-by-side comparison between the Aetna CDHP and the Aetna PPO for Medical Coverage
2014 Side-by-side comparison between the and the for Medical Coverage Medical Coverage Carrier Aetna Aetna Aetna Aetna Deductible Individual $1,750 $3,250 $750 $2,250 Family $3,500 $6,500 $1,500 $4,500
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 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 informationNot applicable Optional. CHE PREFERRED CARE (Home Host) Covered 100%
PLAN FEATURES Catholic Health East PROVIDED BY LIFE INSURANCE COMPANY Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
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 informationPLAN DESIGN AND BENEFITS - NYC Community Plan SM 6-11 PARTICIPATING PROVIDER REFERRED*
Aetna Health Inc. for Referred Benefits Plan Effective Date: 10/1/2011 PLAN FEATURES Deductible (per calendar ) $5,000 Individual $15,000 Family Unless otherwise indicated, the Deductible must be met prior
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 informationPARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
More informationTHE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA)
THE MITRE CORPORATION PPO High Deductible Plan with a Health Saving Account (HSA) Effective Date: 01-01-2016 PLAN FEATURES Annual Deductible $1,500 Employee $3,000 Employee $3,000 Employee + 1 Dependent
More informationTHE MITRE CORPORATION Aetna PPO High Deductible Plan with a Health Saving Account (HSA)
THE MITRE CORPORATION Aetna PPO High Deductible Plan with a Health Saving Account (HSA) Effective Date: 01-01-2017 PLAN FEATURES Annual Deductible $1,500 Employee $3,000 Employee $3,000 Employee + 1 Dependent
More informationMember Services
Member Services 1-800-589-4811 Plan Facts Hours of Operation Website Name of Physician Network Minute Clinic Decision Support Tools 8:00 a.m. to 6:00 p.m. Local Time Monday Friday www.aetna.com Aetna Choice
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 informationThe PPO Savings Plan. Faculty, Staff & Technical Service. Schedule of Benefits
The PPO Savings Plan Faculty, Staff & Technical Service Schedule of Benefits Prepared exclusively for: Employer: The Pennsylvania State University Contract number: 285717 Control number: 285739 Technical
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 informationPARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
More informationNot applicable. Immunizations 1 exam per 12 months for members age 18 to age 65; 1 exam per 12 months for adults age 65 and older.
PLAN FEATURES NON- Deductible (per calendar year) $300 Employee $600 Employee $900 Family $1,800 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
More informationCovered 100%; deductible waived 30%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $5,500 Individual $10,000 Individual $11,000 Family $20,000 Family All covered expenses accumulate separately toward the preferred
More informationFlorida - EPO Aetna Select - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES
PLAN FEATURES Deductible (per calendar year) $100 Individual $200 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Pharmacy expenses do not apply towards the
More information2014 CDPHP Medicare Choices Group PPO Benefit Summary
2014 CDPHP Medicare Choices Group PPO Benefit Summary Services In-Network Out-of-Network Physician Services Primary care physician visits $10 copayment $10 copayment Specialty visits $15 copayment $15
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family All covered expenses, accumulate separately toward the preferred or
More informationSchedule of Benefits (GR-29N OK)
Schedule of Benefits (GR-29N 01-01 01 OK) Employer: Group Policy Number: HS-Real Estate, Inc. dba Hal Smith Restaurant Group GP-493042 Issue Date: April 28, 2017 Effective Date: March 1, 2017 Schedule:
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 informationAetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK. Individual Deductible* $1,000 $2,000. Family Deductible* $2,000 $4,000
Schedule of Benefits Employer: Adobe Systems Incorporated ASC: 660819 Effective Date: January 1, 2012 Schedule: 2B Booklet Base: 1 For: Aetna Choice POS II 80/60 Plan This is an ERISA plan, and you have
More informationPLAN DESIGN AND BENEFITS - PA POS HSA COMPATIBLE NO-REFERRAL 2.4 ($2,500 Ded) PARTICIPATING PROVIDERS
PLAN FEATURES Deductible (per plan year) $2,500 Individual NON- $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All
More informationCDPHP Medicare Choices Group Plan 2014 PPO Renewal Information
CDPHP Medicare Choices Group Plan 2014 PPO Renewal Information Paperwork Due Date: Return on or before 10/31/2013 Health Benefits Administrator Group Number: 10006176 Otsego County Chamber of Commerce
More information(30- to 34-day supply) 100% after $40 copay; significant or new therapeutic class drugs: 50%
C O U N T Y S I N T R A N E T S I T E : H T T P : / / I N T R A N E T. C O. R I V E R S I D E. C A. U S 25 Exclusive Care Select Medicare Coordination Plan Tier 1: Exclusive Care Network Tier 2: Any Provider
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 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 informationFlorida Health Network Option (POS Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Option (POS Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOption Plan 12-2000-70 PLAN FEATURES PARTICIPATING PROVIDERS
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 informationUnlimited/ $1,000,000 per lifetime Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Member Coinsurance Out-of-Pocket Maximum $1,500 $3,000 Individual (per calendar year) $3,000 $6,000 Family Member cost sharing for
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $3,000 Individual $3,000 Individual $6,000 Family $6,000 Family All covered expenses accumulate separeately toward the preferred or
More informationPLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC. Cost Share. $0 Deductible. Unlimited
PLAN FEATURES Deductible (per calendar year) $0 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance Applies to all expenses unless otherwise
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH INC. AND AETNA HEALTH INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $2,500 Individual $5,000 Individual (per calendar year) $5,000 Family $10,000 Family Unless otherwise indicated, the deductible must be met prior to benefits
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 informationFlorida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-Compass PLAN FEATURES Deductible (per calendar
More informationVersion: 15/02/2017 [ TPID: ] Page 1
PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not required Deductible (per calendar year) $1,500 Individual $3,000 Family $3,000 Individual $9,000 Family
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 information$8,000 Family. $6,600 Individual $13,200 Family
PLAN DESIGN AND BENEFITS - GA OAMC 4000 100/70 (2018) GA Group Business 51-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not Required Not Required Deductible
More informationPLAN 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
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 informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
More informationLourdes Health System Proposed Effective Date: Aetna Helathfund Aetna Choice POS ll - ASC Salary Band: Less than $21,000 to $41,999
PROVIDED BY LIFE INSURANCE COMPANY FUND FEATURES HealthFund Amount $750 Employee $1,500 Employee + Spouse $1,500 Employee + Child(ren) $1,500 Family Amount contributed to the Fund by the employer Fund
More information$10,000 Family. $7,000 Individual $14,000 Family
PLAN DESIGN AND BENEFITS - NV Silver AWH Las Vegas HMO 5000 $30 (2018) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable
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 information$4,000 Family. $7,150 Individual $14,300 Family
PLAN DESIGN AND BENEFITS - CA Silver Basic HMO 2000 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable
More information$7,000 Family. $7,500 Individual $15,000 Family
PLAN DESIGN AND BENEFITS - NV Silver AWH Las Vegas HMO 3500 80% $40 (2019) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not
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 informationFlorida Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012. PLAN DESIGN AND BENEFITS MC OA Plan A-50
Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS MC OA Plan 12-3000A-50 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS
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 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 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 informationPLAN DESIGN AND BENEFITS - New York Open Access MC 3-11 HSA Compatible
PLAN FEATURES Deductible (per plan year) $3,000 Individual $6,000 Individual $6,000 Family $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
More informationFlorida Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS Deductible (per calendar year) PLAN DESIGN
More informationRecommended: One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over.
PLAN FEATURES Deductible (per calendar year) $2,000 Individual $4,000 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services,
More informationFlorida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-80 HSA PLAN FEATURES Deductible (per calendar
More informationCoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company.
Individual 80% $500 Deductible Schedule of Benefits CoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company. This Schedule is
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 informationPLAN DESIGN AND BENEFITS - New York Open Access EPO 4-10/10 HSA Compatible
PLAN FEATURES Deductible (per plan year) $3,500 Individual $7,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Individual Deductible can only be met
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $3,000 Individual $5,000 Individual $6,000 Family $10,000 Family All covered expenses accumulate separately toward the preferred or
More informationNo Charge Primary care visit to treat an injury or illness. 20% Specialist care visit
Effective: January 1, 2018 UC Medicare PPO Plan Please Note: this medical plan is a complement to your existing Medicare plan. Medicare benefits are primary and then the benefits of this plan are calculated
More informationCoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company.
QHDHP Individual 80 / 60 $3,000 Deductible CoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company. This Schedule is part of
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 informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA HEALTH INSURANCE COMPANY - SELF-FUNDED
PLAN FEATURES Deductible (per calendar year) $100 Individual $200 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services,
More informationActive and Retiree Medical Benefit Summary Plan Description And Plan Document /
Active and Retiree Medical Benefit Summary Plan Description And Plan Document 7670-00-411309/7670-03-411309 Revised 01-01-2018 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 1 PLAN INFORMATION...
More informationCOVENTRY HEALTH AND LIFE INSURANCE COMPANY 2751 Centerville Road, Suite 400 Wilmington, Delaware SCHEDULE OF BENEFITS CoventryOne SM
COVENTRY HEALTH AND LIFE INSURANCE COMPANY 2751 Centerville Road, Suite 400 Wilmington, Delaware 19808-1627 SCHEDULE OF BENEFITS CoventryOne SM CoventryOne is administered by Coventry Health Care of Delaware,
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 informationCHE PREFERRED CARE (Home Host)
PLAN FEATURES Catholic Health East PROVIDED BY LIFE INSURANCE COMPANY Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
More information$8,000 Family. $6,000 Individual $12,000 Family
PLAN DESIGN AND BENEFITS - FL Silver HNOnly 4000 100 (2016) FL Group Business 2-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
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 informationConnecticut Small Group Open Access QPOS Aetna Health Inc. Plan Effective Date: 10/1/2010 Aetna Health Insurance Company
PLAN FEATURES Deductible (per calendar year) $2,000 Individual NON- $3,000 Individual $4,000 Family $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the preferred or
More informationCoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company.
QHDHP Individual 100 / 80 $$3,000 CoventryOne is administered by Coventry Health Care of Delaware, Inc. and underwritten by Coventry Health and Life Insurance Company. This Schedule is part of Your Policy
More information$14,000 Family. $7,000 Individual. $14,000 Family
PLAN DESIGN AND BENEFITS - NV Bronze PPO 7000 100/70 (2017) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
More informationPLAN DESIGN. Customer Name: Caltech - Mid PPO. Proposed Effective Date: Plan: Mid Option PPO Plan. Organization Name: Aetna
PLAN DESIGN Customer Name: Caltech - Mid PPO Proposed Effective Date: 01-01-2019 Plan: Mid Option PPO Plan Organization Name: Aetna PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year)
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 informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,800 Individual $2,700 Individual within a Family $4,000 Individual $4,000 Individual within a Family $3,600 Family $8,000 Family
More informationPPO HSA HDHP $2,500 90/50
PLAN FEATURES Deductible (per calendar year) $2,500 Individual $2,500 Individual $5,000 Family $5,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $2,000 Individual $1,500 Family $6,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
More information$8,300 $24,900 Maximum Lifetime Benefit
PPO Schedule of Health Plus 2 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
More informationCovered 100%; deductible waived 40%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family All covered expenses accumulate simultaneously toward both the preferred
More informationRetirees with Medicare (RETIREMENT DATE BEFORE March 1, 2015) Benefits Comparison Benefits effective January 1, December 31, 2017
Network Eligible OGB Members Pelican HRA1000 Blue Cross and Blue Shield of Louisiana Preferred Care Providers & Blue Cross National Providers (retirement date BEFORE 3/1/2015) Magnolia Local Plus Blue
More informationPLAN DESIGN. Customer Name: Caltech. Proposed Effective Date: Plan: Low Option OAMC. Organization Name: Aetna
PLAN DESIGN Customer Name: Caltech Proposed Effective Date: 01-01-2019 Plan: Low Option OAMC Organization Name: Aetna PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $3,950 Individual
More information