Access Health CT 2019 Alternative Standard Silver Plan Design Exhibit Individual Market. Page
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1 Access Health CT 2019 Alternative Standard Silver Plan Design Exhibit Individual Market 1
2 Ind Market Silver Coinsurance Plan, 70% AV 2019 Individual Market Silver 70% Plan Medical Deductible $3,500 (2x family) $7,400 (2x family) Rx Deductible $250 (2x family) $500 (2x family) Coinsurance 30% 40% Out-of-pocket Maximum $7,900 (2x family) $15,800 (2x family) Primary Care 30% 40% (after Specialist Care Urgent Care Emergency Room 30% (after 30% (after in-network Ambulance 30% (after 30% (after in-network Inpatient Hospital Outpatient Hospital Advanced Radiology (CT/PET Scan, MRI) Laboratory Mammography Ultrasound maximum, separate for each type Diabetic Supplies & Equipment Durable Medical Equipment Home Health Care 2019 Individual Market Silver 70% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 30% (after Not Covered All Other Medical 30% 40% (after $5 * / 30% / 30% / 30% ded., $200 max per spec AVC Results 2019 AVC Results 70.11% % 2
3 Ind Market Silver Coinsurance Plan, 73% AV 2019 Individual Market Silver 73% Plan Coinsurance Medical Deductible $2,600 (2x family) $7,400 (2x family) Rx Deductible $250 (2x family) $500 (2x family) Coinsurance 30% 40% Out-of-pocket Maximum $6,300 (2x family) $15,800 (2x family) Primary Care 30% 40% (after Specialist Care Urgent Care Emergency Room 30% (after 30% (after in-network Ambulance 30% (after 30% (after in-network Inpatient Hospital Outpatient Hospital Advanced Radiology (CT/PET Scan, MRI) Laboratory Mammography Ultrasound Diabetic Supplies & Equipment Durable Medical Equipment Home Health Care 2019 Individual Market Silver 73% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 30% (after Not Covered All Other Medical 30% 40% (after $5 * / 30% / 30% / 30% ded., $100 max per spec AVC Results 2019 AVC Results 73.52% 3
4 Ind Market Silver Coinsurance Plan, 87% AV 2019 Individual Market Silver 87% Plan Coinsurance Medical Deductible $500 (2x family) $7,400 (2x family) Rx Deductible $50 (2x family) $500 (2x family) Coinsurance 20% 40% Out-of-pocket Maximum $2,300 (2x family) $15,800 (2x family) Primary Care 20% 40% (after Specialist Care 20% (after 40% (after Urgent Care 20% (after 40% (after Emergency Room 20% (after 20% (after in-network Ambulance 20% (after 20% (after in-network Inpatient Hospital 20% (after 40% (after Outpatient Hospital 20% (after 40% (after Advanced Radiology (CT/PET Scan, MRI) 20% (after 40% (after 20% (after 40% (after Laboratory 20% (after 40% (after Mammography Ultrasound 20% (after 40% (after 20% (after 40% (after 20% (after 40% (after Diabetic Supplies & Equipment 20% (after 40% (after Durable Medical Equipment 20% (after 40% (after Home Health Care 2019 Individual Market Silver 87% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 20% (after Not Covered 20% (after 40% (after All Other Medical 20% 40% (after $5 * / 20% / 20% / 20% ded., $60 max per spec AVC Results 2019 AVC Results 87.52% 4
5 Ind Market Silver Coinsurance Plan, 94% AV 2019 Individual Market Silver 94% Plan Coinsurance Medical Deductible $0 $7,400 (2x family) Rx Deductible $0 $500 (2x family) Coinsurance 20% 40% Out-of-pocket Maximum $750 (2x family) $15,800 (2x family) Primary Care 20% 40% (after Specialist Care 20% 40% (after Urgent Care 20% 40% (after Emergency Room 20% 20% Ambulance 20% 20% Inpatient Hospital 20% 40% (after Outpatient Hospital 20% 40% (after Advanced Radiology (CT/PET Scan, MRI) 20% 40% (after 20% 40% (after Laboratory 20% 40% (after Mammography Ultrasound 20% 40% (after 20% 40% (after 20% 40% (after Diabetic Supplies & Equipment 20% 40% (after Durable Medical Equipment 20% 40% (after Home Health Care 2019 Individual Market Silver 94% Plan Preventive 0% 50% (after Basic Pediatric Vision: Routine Eye Exam by Specialist (one exam per 30% (after 50% (after 40% (after 50% (after 50% (after 50% (after 20% Not Covered 20% 40% (after All Other Medical 20% 40% (after $5 * / 20% / 20% / 20% ($60 max per spec AVC Results 2019 AVC Results 94.76% 5
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This is only a summary. If you want more detail about coverage and costs, you can get the complete terms in the policy or plan document at https://www.hioscar.com/forms/?planstate=tx&plandate=2017 or by
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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.bsneny.com or by calling 1-855-344-3425. Important Questions
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 CCH Healthcare: American Plan Administrators/Cigna Coverage for: Individual,
More informationImportant Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific 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.centralpateamsters.com or by calling 1-800-422-8330 (PA)
More informationthis plan begins to pay. If you have other family members on the plan each family member deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Platinum 90 PPO Coverage for: Individual + Family Plan Type:
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.teamsters-hma.com or by calling 1-877-384-2875.
More informationNo You don t have to meet deductibles for specified services, but see the chart starting on page 2 for other costs for services this plan covers.
Molina Healthcare of Utah, Inc.: Molina Silver 150 Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family
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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.landoflincolnhealth.org or by calling 1-888-858-9130.
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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.crystalrunhp.com or by calling 1-844-638-6506. Important
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More informationHighlights of your Health Care Coverage Washington Counties Insurance Fund
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More information$ 0 Does not apply to Vision benefit. Important Questions Answers Why this Matters: What is the overall deductible?
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.vsp.com or by calling 1-800-877-7195. Important Questions
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