2018 Summary of Benefits
|
|
|
- Pauline Gordon
- 6 years ago
- Views:
Transcription
1 Medicare GenerationRx (Employer PDP) 2018 Summary of Benefits January 1, December 31, 2018 S9579 For the NEA Group Part D Program Advanced Plan 2 This is a summary of prescription drug services covered by Medicare GenerationRx (Employer PDP) and what you pay. Transamerica Life Insurance Company is a PDP plan sponsor with a Medicare contract. Enrollment in this plan depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. S9579_18_SB_EGWP_NEAADVANCED2 18SB127
2 Who Can Join This Plan? To join Medicare GenerationRx, you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, be eligible for these benefits from your employer group health plan and live in our service area. Our service area includes all 50 states, the District of Columbia and the U.S. Territories. Which Pharmacies Can I Use? Medicare GenerationRx has a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's pharmacy directory on our web site Or, call us and we will send you a copy of the pharmacy directory. Which Drugs are Covered? We cover Part D drugs. For a complete plan formulary (list of prescription drugs covered by the plan), please call Member Services. You can also see the complete plan formulary and any restrictions on our web site: Tips for Comparing Medicare Choices If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document may be available in other formats such as Braille or large print. 2
3 Premiums and Benefits Medicare GenerationRx (Employer PDP) What you should know Monthly Part D Plan Premium $135 You must continue to pay your Medicare Part B premium. Deductible You pay $250 per year for Part D prescription drugs. You pay the full cost of your drugs until the yearly deductible is met. Part D Prescription Drugs Your cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy- specific cost sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. Standard Retail Pharmacy (30-day supply) Standard Retail Pharmacy (90-day supply) Mail Order Pharmacy (90-day supply) Initial Coverage: After you pay your yearly deductible, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date total drug costs (your payments plus any Part D plan s payments) total $3,750. Tier 1: Preferred Generic $5 $15 $15 Tier 2: Generic $10 $30 $30 Tier 3: Preferred Brand 20% of the cost 20% of the cost 20% of the cost Tier 4: Non-Preferred Drug 25% of the cost 25% of the cost 25% of the cost Tier 5: Specialty 25% of the cost 25% of the cost 25% of the cost Coverage Gap: The Coverage Gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. When you are in the Coverage Gap, you pay 35% of the cost for covered brand name drugs (plus a portion of the dispensing fee). For covered generic drugs, you pay either $5 for Tier 1: Preferred Generic and $10 for Tier 2: Generic or 44% of the costs, whichever is lower, until your out-of-pocket costs reach $5,000, which is the end of the Coverage Gap. Not everyone will enter the Coverage Gap. Catastrophic Coverage: After your yearly out-of-pocket drug costs reach $5,000, you pay the greater of: 5% of the cost, OR $3.35 copay for generic or drugs treated as generic and $8.35 copay for all other drugs. 3
4 Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). (Arabic) ال عرب ية ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 117(. Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711) S9579_18_LANGASSISTANCE_EGWP Transamerica Life Insurance Company is a PDP plan sponsor with a Medicare contract. Enrollment in this plan depends on contract renewal.
5 Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください (Farsi) ف ار سی توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رايگان برای شما فراهم می باشد. با (711 (TTY: تماس بگیريد. ह द (Hindi) ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर S9579_18_LANGASSISTANCE_EGWP Transamerica Life Insurance Company is a PDP plan sponsor with a Medicare contract. Enrollment in this plan depends on contract renewal.
6 For more information, please call Member Services or visit our web site: Member Services Phone Number Call Toll-free TTY users should call 711. We are open 24 hours a day, 365 days a year.
AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT
AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT The Teamsters Local 294- Albany Area Trucking and Allied Industries
Welcome to Cigna Vision Schedule of Vision Coverage
Summary of Benefits Cigna Health and Life Insurance Company Cigna Vision Arlington County Government Welcome to Cigna Vision Schedule of Vision Coverage Coverage In-Network Benefit Out-of-Network Benefit
Annual Notice of Changes for 2018 for the NEA Group Part D Program Advanced Plan
Medicare GenerationRx (Employer PDP) offered by Transamerica Life Insurance Company Annual Notice of Changes for 2018 for the NEA Group Part D Program Advanced Plan You are currently enrolled as a member
Summary of Material Modifications 11/1/2018 SUMMARY OF MATERIAL MODIFICATIONS PLAN BENEFIT CHANGES TO: All Covered Plan Participants
11/1/2018 SUMMARY OF MATERIAL MODIFICATIONS TO: All Covered Plan Participants FROM: The Writers Guild- Industry Health Fund This document is a Summary of (SMM), intended to notify you of changes to your
COBRA CONTINUATION COVERAGE ELECTION FORM
Instructions: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you have 60 days after the date of this notice to decide whether you want to elect
Cigna Health and Life Insurance Company. Welcome to Cigna Vision Schedule of Vision Coverage. Benefit
Summary of Benefits Cigna Health and Life Insurance Company Cigna Vision UT Graduate Medical Education Program - Vision Welcome to Cigna Vision Schedule of Vision Coverage Coverage In-Network Benefit Out-of-Network
Summary of Benefits. Humana Preferred Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina.
SBOSB026 2018 Summary of Benefits Humana Preferred Rx Plan (PDP) State of North Carolina Our service area includes the following state(s): North Carolina. GNHH4HIEN_18 S5884133000SB18 2018 Summary of
MEDICARE. Go365 Mall Catalog MAKE HEALTHIER CHOICES
MAKE HEALTHIER CHOICES MEDICARE Go365 Mall Catalog With Go365 by Humana, you re on the path to achieving a healthier lifestyle for you and the people you love. You re also on the way to earning Go365 Bucks,
Dear Health First Health Plans Member:
Dear Health First Health Plans Member: You are enrolled in a Medicare Advantage plan offered by Health First Health Plans. A snapshot of the 2017 plans can be found on the first page of the attached form.
2017 Summary of Benefits. Peach State Health Plan Medicare Advantage (HMO) DeKalb and Fulton Counties H7173, Plan 002
2017 Summary of Benefits Peach State Health Plan Medicare Advantage (HMO) DeKalb and Fulton Counties H7173, Plan 002 H7173-002_2017_SB_Accepted_09062016 Summary of Benefits January 1, 2017 December 31,
This is a summary of drug and health services covered by Florida Hospital Care Advantage effective January 1, 2019
This is a summary of drug and health services covered by Florida Hospital Care Advantage effective January 1, 2019 Benefits Monthly Plan Premium In addition, you must keep paying your Medicare Part B premium.
Accenture Leadership United States Benefit Plans Summary Plan Description
Accenture Leadership United States Benefit Plans Summary Plan Description (Effective January 1, 2017) TABLE OF CONTENTS INTRODUCTION 1 BECOMING ACCENTURE LEADERSHIP 1 VOLUNTARY COVERAGE 1 Choices 1 Life
2017 Summary of Benefits. Peach State Health Plan Medicare Advantage (HMO) Chattahoochee, Harris, and Muscogee Counties H7173, Plan 003
2017 Summary of Benefits Peach State Health Plan Medicare Advantage (HMO) Chattahoochee, Harris, and Muscogee Counties H7173, Plan 003 H7173-003_2017_SB_Accepted_09062016 Summary of Benefits January 1,
Your Plan: 2019 HMO Plan (1VYT) -Medical benefits only plan for Retirees with Medicare A&B Your Network: California Care HMO
Anthem Blue Cross ACWA JPIA C00361 Your Plan: 2019 HMO Plan (1VYT) -Medical benefits only plan for Retirees with Medicare A&B Your Network: California Care HMO This summary of benefits is a brief outline
2017 Summary of Benefits. Trillium Advantage TLC ISNP (HMO SNP) Lane County H2174, Plan 003
2017 Summary of Benefits Trillium Advantage TLC ISNP (HMO SNP) Lane County H2174, Plan 003 H2174-003_2017_SB_Accepted_09082016 Summary of Benefits January 1, 2017 December 31, 2017 This is a summary of
Your Plan: 2019 Consumer Driven Health Plan (CDHP) (1DMW) Medical benefits only plan for retirees with Medicare A&B Your Network: Prudent Buyer PPO
Anthem Blue Cross ACWA JPIA C00361 Your Plan: 2019 Consumer Driven Health Plan (CDHP) (1DMW) Medical benefits only plan for retirees with Medicare A&B Your Network: Prudent Buyer PPO This summary of benefits
Your Plan: 2019 Advantage PPO Plan (1VYX) Medical benefits only plan for Retirees with Medicare A&B Your Network: Prudent Buyer PPO
Anthem Blue Cross ACWA JPIA C00361 Your Plan: 2019 Advantage PPO Plan (1VYX) Medical benefits only plan for Retirees with Medicare A&B Your Network: Prudent Buyer PPO This summary of benefits is a brief
2017 Summary of Benefits. Superior HealthPlan Medicare Advantage (HMO) Collin, Dallas, Denton and Smith Counties H0062, Plan 002
2017 Summary of Benefits Superior HealthPlan Medicare Advantage (HMO) Collin, Dallas, Denton and Smith Counties H0062, Plan 002 H0062-002_2017_SB_Accepted_09062016 Summary of Benefits January 1, 2017 December
2017 Summary of Benefits
2017 Summary of Benefits Sunshine Health Medicare Advantage (HMO) Duval County H9276, Plan 001 H9276-001_2017_SB_Accepted_09062016 Summary of Benefits January 1, 2017 December 31, 2017 This is a summary
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because Horizon Blue Cross Blue Shield of New Jersey denied your request for coverage of (or payment for) a prescription drug, you have
2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx
2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx This is a summary of health and drug services covered by Presbyterian MediCare PPO January 1, 2019 to December 31, 2019. To enroll
2018 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx
2018 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx This is a summary of health and drug services covered by Presbyterian MediCare PPO January 1, 2018 to December 31, 2018. To enroll
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: 7050 S Union Park Center Drive Suite 200 Midvale, Utah 84047 Fax Number: (866) 290-1309
Benefits Group Plus A (HMO) Group Plus B (HMO) Group (HMO-POS) Monthly Plan Premium In addition, you must keep paying your Medicare Part B
Medicare Advantage (Employer Group Plans) This is a summary of drug and health services covered by Health First Health Plans effective January 1, 2019 Monthly Plan Premium In addition, you must keep paying
Enrollment form. Individual Plan. How to fill out this form. Next steps. Georgia Region Individual Plan
Kaiser Permanente Senior Advantage (HMO) or Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) Individual Plan Enrollment form Georgia Region Individual Plan Have you thought about enrolling
2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx
2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2017 to
Medical Claim Form. Alliant Health Plans PO Box 2667 Dalton, GA Fax: (866)
Medical Claim Form Why is this form used? Alliant Health Plans members may use the Medical Claim Form to file a claim for any medical services received from Out of Network providers. In Network providers
2017 Summary of Benefits
2017 Summary of Benefits Sunshine Health Medicare Advantage (HMO) Pasco, Pinellas and Polk Counties H9276, Plan 002 H9276-002_2017_SB_Accepted_09062016 Summary of Benefits January 1, 2017 December 31,
Medicare Advantage This is a summary of drug and health services covered by Health First Health Plans effective January 1, 2019
Medicare Advantage This is a summary of drug and health services covered by Health First Health Plans effective January 1, 2019 Benefits Monthly Plan Premium In addition, you must keep paying your Medicare
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Florida Duval H1032 Plan 073 1/1/2018 12/31/18 WellCare Value (HMO) H1032_WCM_02977E WellCare 2017 FL8WMRSOB02977E_0073 Summary of Benefits January 1,
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans North Carolina Buncombe H0712 Plan 024 1/1/2018 12/31/18 H0712_WCM_03269E WellCare 2017 NC8CMRSOB03269E_0024 Summary of Benefits January 1, 2018 December
Coverage for: Individual +Family Plan Type: PPO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Greater Clark County Schools Corporation: PPO Plan Coverage for: Individual
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans North Carolina Durham, Orange H0712 Plan 022 1/1/2018 12/31/18 WellCare Value (HMO) H0712_WCM_03267E WellCare 2017 NC8CMRSOB03267E_0022 Summary of Benefits
Evidence of Coverage:
January 1 December 31, 2018 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of Medicare GenerationRx (Employer PDP) for the NEA Group Part D Program This booklet gives you the
Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of Medicare GenerationRx (Employer PDP) for the NEA Group Part D Program
January 1 December 31, 2018 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of Medicare GenerationRx (Employer PDP) for the NEA Group Part D Program This booklet gives you the
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus Coverage Period: 01/01/2017-12/31/2017 Bronze Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:
2018 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx
2018 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2018 to
2018 Summary of Benefits: Presbyterian Dual Plus (HMO SNP)
MEDICARE ADVANTAGE PLANS 2018 Summary of Benefits: Presbyterian Dual Plus (HMO SNP) This is a summary of health and drug services covered by Presbyterian Dual Plus (HMO SNP) January 1, 2018 to December
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans California Los Angeles H5087 Plan 017 1/1/2018 12/31/18 Easy Choice Plus Plan (HMO) H5087_WCM_02971E WellCare 2017 CA8WCMSOB02971E_0017 Summary of Benefits
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Texas Bexar, Dallas, Denton, El Paso, Fort Bend, Harris H1264 Plan 022 1/1/2018 12/31/18 WellCare Dividend Prime (HMO) H1264_WCM_03293E WellCare 2017 TX8TMRSOB03293E_0022
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus Coverage Period: 01/01/2017-12/31/2017 Silver Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual
2017 Enrollment Request Form
2017 Enrollment Request Form Please contact Health First Health Plans if you need information in another language or format (Braille). To Enroll in Health First Health Plans, Please Provide the Following
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans South Carolina Cherokee, Greenville, Pickens, Saluda, Spartanburg, Union H1416 Plan 052 001 1/1/2018 12/31/18 WellCare Value (HMO) H1416_WCM_03283E WellCare
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus
Cigna Health and Life Insurance Co.: Open Access Plus or Local Plus Coverage Period: 12/01/2016-11/30/2017 Bronze Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Florida Brevard, Charlotte, Duval, Escambia, Gadsden, Highlands, Lee, Sarasota, St. Lucie, Walton H1032 Plan 188 001 1/1/2018 12/31/18 WellCare Dividend
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans New York Albany, Broome, Erie, Niagara, Oneida, Rensselaer, Rockland, Saratoga, Schenectady H3361 Plan 136 002 1/1/2018 12/31/18 WellCare Value (HMO) H3361_WCM_03275E
Advantage Plus Enrollment Form
Page 1 of 6 Advantage Plus Enrollment Form Colorado Region Thank you for your interest in our Advantage Plus plans. Combining the benefits of Advantage Plus with your Kaiser Permanente Senior Advantage
Individual Enrollment Request Form ( )
Page 1 of 5 Individual Enrollment Request Form Please contact PHP (HMO SNP) if you need information in another language or format (Braille). To enroll in PHP (HMO SNP), please provide the following information:
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Connecticut FairField, Hartford, Litchfield, Middlesex, New London, Tolland H0712 Plan 021 1/1/2018 12/31/18 WellCare Preferred (HMO) H0712_WCM_02974E
Magellan Rx Medicare Basic (PDP) Summary of Benefits
2018 Magellan Rx Medicare Basic (PDP) Summary of Benefits January 1, 2018 December 31, 2018 This Summary of Benefits booklet gives you a summary of what Magellan Rx Medicare Basic (PDP) covers and what
Summary of Benefits. Allwell Medicare Premier (HMO) Osceola County, Florida H
2018 Summary of Benefits Osceola County, Florida H9276-009 Benefits effective January 1, 2018 H9276_18_2870SB_Accepted 09072017 This booklet provides you with a summary of what we cover and your cost-sharing.
Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form *1989* This form may be used for Allwell Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
2017 Summary of Benefits
2017 Summary of Benefits Buckeye Health Plan Medicare Advantage (HMO SNP) Allen, Ashtabula, Auglaize, Brown, Carroll, Clark, Clermont, Cuyahoga, Defiance, Erie, Fulton, Geauga, Greene, Hamilton, Hancock,
Delta Dental Individual and Family SM
Delta Dental Individual and Family SM ENROLLMENT FORM The effective date of your individual dental plan will be the first of the month following receipt of this completed enrollment form and payment, so
Introduction to the Health Options Online Payment System. October 2016
Introduction to the Health Options Online Payment System October 2016 NON-DISCRIMINATION NOTICE Community Health Options does not view or treat people differently because of their race, color, national
IMPORTANT NOTICE: Your Medicare plan won t be offered in 2018
IMPORTANT NOTICE: Your Medicare plan won t be offered in 2018 Keep this letter. It s proof that you have a special right to buy a Medigap policy
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Plan Type: This is only a summary. For more information about your coverage, or to get a copy of
Important Information About Your 2018 PERACare Medicare Coverage with Anthem Blue Cross and Blue Shield and SilverScript
Important Information About Your 2018 PERACare Medicare Coverage with Anthem Blue Cross and Blue Shield and SilverScript NEW PRESCRIPTION DRUG PROVIDER SILVERSCRIPT (AFFILIATED WITH CVS CAREMARK ) In our
2019 Summary of Benefits: Presbyterian Dual Plus (HMO SNP)
2019 Summary of Benefits: Presbyterian Dual Plus (HMO SNP) This is a summary of health and drug services covered by Presbyterian Dual Plus (HMO SNP) January 1, 2019 to December 31, 2019. To enroll in Presbyterian
Important Questions Answers Why this Matters:
USA Health &Dental Plan STANDARD PLAN #79873/78380 Coverage Period: Beginning on or after 1/01/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage For: Individual + Family
Plan for Medicare: Understand your options
2017 Education Brochure Plan for Medicare: Understand your options You have many options when choosing your Medicare coverage The right one for your friends or even your spouse may not be the right one
Important Questions Answers Why this Matters:
USA Health & Dental Plan BASE PLAN #13515/86113 Coverage Period: Beginning on or after 01/01/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage For: Individual + Family
Group HMO Silver 4 Sub On Exchange Coverage Period: 01/01/ /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.phs.org. or by calling 1-800-923-6980. Important Questions
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans North Carolina Durham, Orange, Henderson, Madison, McDowell, Polk, Transylvania, Buncombe H0712 Plan 025 1/1/2018 12/31/18 WellCare Access (HMO SNP) H0712_WCM_03337E
Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form *1989* This form may be used for Allwell Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans South Carolina Abbeville, Cherokee, Greenville, Laurens, McCormick, Newberry, Richland, Saluda, Spartanburg, Union H7326 Plan 002 1/1/2018 12/31/18 H7326_WCM_03314E
Dependent Eligibility Verification
SPRING 2017 for Retired Members Dependent Eligibility Verification T his year, the Trust Fund Office (TFO) will perform a Dependent Eligibility Verification. This will ensure all Members who have Dependents
SBOSB015. Summary of Benefits. Humana Preferred Rx Plan (PDP) State of Missouri
SBOSB015 2017 Summary of Benefits Humana Preferred Rx Plan (PDP) State of Missouri GNHH4HIEN_17 S5884140000SB17 201 7 Summary of Benefits Humana Preferred Rx Plan (PDP) S5884-140 State of Missouri S5884_SB_PDP_PDP_140000_2017
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorizaton Department PO Box 419069 Rancho Cordova, CA 95741 Fax
Coverage for: Individual, Individual + Family Plan Type: HMO
Summary of Benefits and Coverage: What this plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 CHRISTUS Health Plan: New Mexico Silver Low-Deductible Limited CS Coverage
$0 at IHCP or with IHCP referral at non-ihcp; $2,400/individual or $4,800/family. Doesn t apply to Preventive care.
Summary of Benefits and Coverage: What this plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 CHRISTUS Health Plan: New Mexico American Indian Gold Statewide Limited
You don t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.
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.bcbswny.com or by calling 1-855-344-3425. Important Questions
Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form *1989* This form may be used for Allwell Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
Summary of Benefits Optional Supplemental Benefits
SBOSB032 2018 Summary of Benefits Optional Supplemental Benefits HumanaChoice R4182-004 (Regional PPO) Region 17 State of Texas Our service area includes the following state(s): Texas. GNHH4HGEN_18 R4182004000SB18
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Georgia Barrow, Bryan, Butts, Chatham, Chattahoochee, Cherokee, Clayton, Columbia, DeKalb, Douglas, Fayette, Forsyth, Fulton, Glynn, Gwinnett, Harris,
SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO H4093, PLAN 003
SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO H4093, PLAN 003 This is a summary of drug and health services covered by Provider Partners Health Plan of Pennsylvania (PPHP-PA) HMO.
Summary of Benefits. Allwell Medicare Premier (HMO) Broward County, Florida H
2018 Summary of Benefits Broward County, Florida H9276-013 Benefits effective January 1, 2018 H9276_18_2781SB_A_Accepted 09172017 1 This booklet provides you with a summary of what we cover and your cost-sharing.
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA 95741
2019 Summary of Benefits
Tamarra D. PHP Care Coordinator 2019 Summary of H3132 Broward, Duval and Miami-Dade Counties January 1, 2019 December 31, 2019 is Medicare Advantage HMO plan with a Medicare contract. Enrollment in PHP
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2019 Plan Type: HMO.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Coverage for: Single/Family Plan Type: HMO. The Summary of Benefits and
Annual Notice of Changes for 2017
Classic Plan (HMO-POS) offered by Health First Health Plans Annual Notice of Changes for 2017 You are currently enrolled as a member of the Classic Plan (HMO-POS). Next year, there will be some changes
Enrollment form. Individual Plan. How to fill out this form. Next steps. Colorado Region Individual Plan
Kaiser Permanente Senior Advantage (HMO) or Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) Individual Plan Enrollment form Colorado Region Individual Plan Have you thought about enrolling
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Georgia Barrow, Bryan, Butts, Chatham, Chattahoochee, Clayton, Columbia, DeKalb, Douglas, Fayette, Forsyth, Harris, Henry, McDuffie, McIntosh, Meriwether,
Bronze Value Plan Off-Exchange. Schedule of Benefits
Schedule of Benefits / 1 Bronze Value Plan Off-Exchange Schedule of Benefits The Schedule of Benefits is a summary of your Benefits and Cost Sharing. The definitions stated in your Contract apply to this
Annual Notice of Changes
Annual Notice of Changes Arkansas For more information, contact Tribute Health Plan of Arkansas (HMO-POS SNP) from 8:00 a.m. to 8:00 p.m., 7 days a week at 1-866-583-4649 (TTY users call 711) or visit
2019 Summary of Benefits
2019 Summary of Benefits Medicare Advantage Plans North Carolina Buncombe H0712 Plan 024 WellCare Value (HMO) H0712_WCM_16292E_M WellCare 2018 NC9CMRSOB16292E_0024 2019 Summary of Benefits January 1, 2019
2019 Summary of Benefits
2019 Summary of Benefits Medicare Advantage Plans North Carolina Durham, Orange, Person H0712 Plan 022 WellCare Value (HMO) H0712_WCM_16294E_M WellCare 2018 NC9CMRSOB16294E_0022 2019 Summary of Benefits
Idaho MedPlus. Care Plus. Benefit Guide. Blue Cross of Idaho Care Plus, Inc. An Independent Licensee of the Blue Cross and Blue Shield Association
Care Plus 2017 Benefit Guide Blue Cross of Care Plus, Inc. An Independent Licensee of the Blue Cross and Blue Shield Association Form No. 16-707 (09-16) Policy Form No. 18-544 (01-17) Policy Form No. 18-545
Summary of Benefits. Blue Cross MedicareRx (PDP) SM. January 1, 2018 December 31, 2018
Summary of Benefits Blue Cross MedicareRx (PDP) SM January 1, 2018 December 31, 2018 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list
2019 Qualified Health Plan (QHP) transparency reporting for Individual HMO
2019 Qualified Health Plan (QHP) transparency reporting for Individual HMO Information on Explanation of Benefits (EOB) Your EOB is a statement that shows what health services you received, what bills
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA 95741
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 Plan Type: HMO.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Coverage for: Single/Family Plan Type: HMO. The Summary of Benefits and
2018 Summary of Benefits
2018 Summary of Benefits Allwell Medicare (HMO) Butler, Greene, Hamilton, and Montgomery counties, Ohio H0724--002 Benefits effective January 1, 2018 H0724_18_2930SB_A Accepted 09172017 This booklet provides
NY MVP Premier Plus HDHP Silver 3
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 Coverage for: Single/Family Plan Type: HDHP. The Summary of Benefits and
2019 Summary of Benefits PrimeTime Health Plan. PCC Airfoils (HMO-POS) E30040
2019 Summary of Benefits PrimeTime Health Plan PCC Airfoils (HMO-POS) E30040 This is a summary of drug and health services covered by PrimeTime Health Plan PCC Airfoils from January 1, 2019 December 31,
Summary of Benefits Optional Supplemental Benefits
SBOSB030 2018 Summary of Benefits Optional Supplemental Benefits Humana Gold Plus H1036-233 (HMO) Raleigh Raleigh Metro Area Our service area includes the following county/counties in North Carolina: Wake.
Select $4,000 HDHP,
Select $4,000 HDHP, 400771 Coverage Period: 01/01/2019-12/31/2019 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: EPO The Summary of Benefits
2018 Summary of Benefits
2018 Summary of Benefits Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry and Rockdale counties, Georgia H7173--002 Benefits effective January 1, 2018 H7173_18_2926SB Accepted 09172017 This booklet provides
$100 Deductible $20 Copayment HMO Plan
Plan Number: 1701809 Out-of-Network: Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Primary Care Office Visits No $20 Example: Office visits with your Primary Care Provider
Add medical coverage End medical coverage First name MI Last name Gender:
Instructions 605919158 Please select one: I m the subscriber, new subscriber, or person responsible for payment. First name Kaiser Permanente for Individuals and Families Account Change Form Georgia There