WVURC HIGHMARK BC/BS PLAN COMPARISON
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- Jeffery Peters
- 5 years ago
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1 EFFECTIVE DATE Blue Distinction Centers Available Benefit Period (used for and Coinsurance limits) (Applies to Network and Non-Network Benefits combined) ($5000 ) December 1, 2017 None Available Centers Available Centers Available January 1 through December 31 (Calendar Year) Centers Available Family (may be met collectively) Note: All Services are subject to the unless otherwise specified. Coinsurance Limit: Family (may be met collectively) Maximum Out of-pocket Family (may be met collectively) $200 $400 $1,000 $2,000 Network & Non-Network Coinsurance dollars cross apply. $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined Standard Standard Blue Distinction Center Standard Blue Distinction Center $250 $5,000 $500 $10,000 Blue Distinction Center $1,250 $2,500 $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined Standard $2,500 $5,000 Blue Distinction Center $6,600 $13,200 Includes:, Network & Non-Network Coinsurance Limits combined $1,500 $3,000 $1,500 $3,000 Non-Network Liability Lifetime Maximum Benefit for all Covered Services BENEFIT HIGHLIGHTS Primary Care Medical Office Visit / Office Consultation - Applies to Charges for Visit only. Does not apply to other Services received during Visit. Specialist Care Medical Office Visit / Office Consultation (Includes Specialist Virtual Visits). Applies to Charges for Visit only. Does not apply to other Services received during Visit. NETWORK ONLY $15/Office Visit, $100 thereafter, No Non $15/Office Visit, $100 thereafter, $20/Office Visit, $100 thereafter, No Non $25/Office Visit, $100 thereafter, No $20/Office Visit, $100 thereafter, No Non $25/Office Visit, $100 thereafter, No 100% After 100% After Urgent Care Copay Co-Pay applies to Charges for Visit only. Does not apply to other Services received during Visit. Co-Pays do not apply to or Coinsurance limits. $50 per Office Visit $50 per Office Visit 100% After Virtual Visit Originating Site Telemedicine3 100% $10 per Visit,, 100% After 100% After
2 Prescription Drug Family PRESCRIPTION DRUGS Prescription Drugs are provided through a Preferred Retail Pharmacy Network If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes brand necessary (DAW) on the prescription, or if no generic equivalent exists. Maximum 34 day Supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket. ($5000 ) NETWORK ONLY None None Member pays 30% or $5. Maximum out of pocket $75 30% Coinsurance, No Maximum out of pocket $100 None None None None. Maximum out of pocket $75 Specialty Drugs: Member pays 30% Coinsurance, No Maximum out of pocket $100 whichever is greater.. Maximum out of pocket $75 30% Coinsurance, Maximum out of pocket $100 Integrated with medical Integrated with medical 100% After Additional Benefits with Prescription - Guidelines as determined by certain Governmental Agencies. You may access this information at You may also contact Member Services Mail Order Drugs If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes brand necessary (DAW) on the prescription, or if no generic equivalent exists. Maximum 90 day supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket Routine Adult Physical Exams Adult Immunizations Colorectal Cancer Screening Routine Gynecological Exam- Including a Pap Test Mammograms, annual routine & medically necessary Mammograms, annual routine & medically necessary Diagnotic services and procedures Routine Pediatric Physical Exams Pediatric Immunizations Diagnostic Services & Procedures Member pays 30% or $5 Maximum out of pocket $100 30% Coinsurance, No Maximum out of pocket $200 PREVENTIVE CARE SERVICES Maximum out of pocket $100 Specialty Drugs: Member pays 30% Coinsurance, No Maximum out of pocket $200 Routine: Medically Necessary: 100%, No deductible Routine: 100%, No Medically Necessary: after deductible whichever is greater. Maximum out of pocket $100 30% Coinsurance, Maximum out of pocket $200 Routine: Medically Necessary: 100% after deductible 100% After Routine: Medically Necessary: 100% after deductible
3 AUTISM SPECTRUM DISORDER Services for diagnosis and treatment of Autism Spectrum Disorder. (See Section V for additional information.) Covered Services will be paid according to the benefit category (e.g. speech therapy, office visit). ($5000 ) In-Hospital Medical Visit Surgery, Assistant to Surgery, Anesthesia Second Surgical Opinion Consultants (Outpatient) Maternity Care - Dependent daughters are covered. Newborn Care including circumcision. Occupational Therapy ( Habilitative) PHYSICIAN SERVICES Maximum 30 visits per Benefit Period. Limitations are for Physician and Outpatient Facility Services, Physician and Outpatient Facility Services, Network and Non- Network, Physician and Outpatient Facility Services, Network and Non-Network, Rehabilitative and Physical Therapy- ( Habilitative) Maximum 30 visits per Benefit Period. Limitations are for Physician and Outpatient Facility Services, Network and Non-Network, Physician and Outpatient Facility Services, Network and Non-Network, Rehabilitative and Spinal Manipulations- ( Habilitative) Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy ( Habilitative) when necessary due to a medical condition. Temporomandibular Joint Dysfunction / Craniomandibular Disorders Maximum 30 visits per Benefit Period. Limitations are for Network and Non- Network, Maximum 30 visits per Benefit Habilitative, combined.. Habilitative, combined. Diagnostic, X-ray, Lab and Testing Allergy Testing and Treatment
4 Unlimited Days Semi-Private Room and Board INPATIENT HOSPITAL / FACILITY SERVICES (Bariatric Surgery; Cardiac Care; Complex and Rare Cancer Care; Knee and Hip Replacement; Spine Surgery and Transplants received at approved Blue Distinction Centers will be subject to the Blue Distinction Center deductible and coinsurance limits) ($5000 ) (Bariatric Surgery; Cardiac Care; Complex and Rare Cancer Care; Knee and Hip Replacement; Spine Surgery and Transplants received at approved Blue Distinction Centers will be subject to the Blue Distinction Center deductible and coinsurance limits) Ancillaries, Drugs, Therapy Services, X-ray and Lab General Nursing Care Surgical Services Birthing Center Care / Maternity Services - Dependent daughters are covered. Pre-Admission Testing Diagnostic, X-ray, Lab and Testing Surgery, Operating Room Occupational Therapy ( Habilitative) Maximum 30 visits per Benefit Rehabilitative and OUTPATIENT HOSPITAL / FACILITY SERVICES High Option B Option 2B 80/20, ( Habilitative) Limitations are for Physician and Outpatient Facility Services, Physical Therapy- ( Habilitative) Maximum 30 visits per Benefit Rehabilitative and, ( Habilitative)Limitations are for Physician and Outpatient Facility Services, Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy ( Habilitative) when necessary due to a medical condition. Outpatient Mental Health Services Outpatient Substance Abuse Services Inpatient Mental Health Care Services Inpatient Substance Abuse Care Services BEHAVIORAL HEALTH SERVICES
5 Emergency Accident Care and /or Emergency Medical Care provided in the ER- ER copay does not apply to or Coinsurance limits. EMERGENCY CARE SERVICES $100 per visit,, $150 per visit, thereafter, subject to deductible ($5000 ) $150 per visit,, subject to deductible Emergency Ambulance Non-Emergency Medical Care provided in the ER Non-Emergency Ambulance Services NON-EMERGENCY CARE SERVICES $150 per visit, thereafter, subject to deductible $150 per visit,, subject to deductible Private Duty Nursing - Maximum 35 visits per calendar year Note: Maximums are Network and Non-Network combined. OTHER COVERED SERVICES Skilled Nursing Facility: Maximum 200 days per calendar year Day 1-100, 100%, No Day ,, Durable Medical Equipment and Oxygen at home Orthotic Devices and Prosthetic Appliances Home Health Care : Maximum 200 Visits Note: Maximums are Network and Non-Network combined Day 1-100, 100%, No Day ,, Maximum 100 Visits Note: Maximums are Network and Non-Network combined. (Max 100 Visits) (Max 100 Visits) Hospice Care Diabetes Education & Control Subject to, then $20 Co-pay per Office Visit, 100% thereafter
6 Human Organ Transplant Bone Marrow Procedures Eligible Dependent Age Limitation Includes transportation, meals and lodging. Includes transportation, meals and lodging. HUMAN ORGAN TRANSPLANT / BONE MARROW PROCEDURES Non 100% Non 100% ($5000 ) Coverage stops at the end of the month of the 26th birthday for an adult dependent who is an Eligible Dependent. ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV. MEDICAL MANAGEMENT & POLICY MUST BE CONTACTED PRIOR TO A PLANNED ADMISSION OR WITHIN 48 HOURS OF AN EMERGENCY OR MATERNITY-RELATED INPATIENT ADMISSION. BE SURE TO VERIFY THAT YOUR PROVIDER IS CONTACTING MM&P FOR PRECERTIFICATION. IF THIS DOES NOT OCCUR AND IT IS LATER DETERMINED THAT ALL OR PART OF THE INPATIENT STAY WAS NOT MEDICALLY NECESSARY OR APPROPIRATE, YOU MAY BE RESPONSIBLE FOR PAYMENT OF ANY COSTS NOT COVERED. PAYMENT IS BASED ON THE PLAN ALLOWANCE. THE PLAN ALLOWANCE WILL GENERALLY BE LESS FOR SERVICES RECEIVED FROM A NON-NETWORK PROVIDER. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY. SERVICES ARE PROVIDED FOR ACUTE CARE FOR MINOR ILLNESSES. SERVICES MUST BE PERFORMED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER. VIRTUAL BEHAVIORAL HEALTH VISITS PROVIDED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER ARE ELIGIBLE UNDER THE OUTPATIENT MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT. SERVICES ARE LIMITED TO THOSE LISTED ON THE HIGHMARK PREVENTIVE SCHEDULE (WOMEN'S HEALTH PREVENTIVE SCHEDULE MAY APPLY). AGE AND FREQUENCY LIMITS MAY APPLY. FOR A CURRENT SCHEDULE OF COVERED SERVICES, LOG ONTO YOUR HIGHMARK WV MEMBER WEBSITE, AT OR CALL MEMBER SERVICE AT THE TOLL- FREE NUMBER LISTED ON THE BACK OF YOUR ID CARD. EFFECTIVE WITH PLAN YEARS BEGINNING ON OR AFTER JANUARY 1, 2017, THE NETWORK TOTAL MAXIMUM OUT-OF-POCKET AS MANDATED BY THE FEDERAL GOVERNMENT MUST INCLUDE DEDUCTIBLE, COINSURANCE, COPAYS, AND ANY QUALIFIED MEDICAL AND PRESCRIPTION EXPENSES. THE TOTAL MAXIMUM OUT-OF-POCKET CANNOT BE MORE THAN $7,150 FOR INDIVIDUAL AND $ FOR TWO OR MORE PERSONS. ANTI-CANCER MEDICATIONS ORALLY ADMINISTERED OR SELF-INJECTED. DEDUCTIBLE, COPAYMENT AND COINSURANCE AMOUNTS FOR PATIENT ADMINISTERED ANTI-CANCER MEDICATIONS THAT ARE COVERED BENEFITS ARE APPLIED ON NO LESS FAVORABLE BASIS THAN FOR PROVIDER INJECTED OR INTRAVENOUSLY ADMINISTERED ANTI- CANCER MEDICATIONS. COPAY DIFFERENTIALS APPLY TO HIGHMARK PCP PROVIDERS IN PA, WV & DE. BENEFITS FOR EMERGENCY AMBULANCE SERVICES RENDERED BY A NON-NETWORK PRVIDER WILL BE SUBJECT TO THE SAME COST-SHARING AMOUNT, IF ANY, THAT IS APPLICABLE TO NETWORK SERVICES. THE MEMBER WILL BE RESPONSIBLE FOR ANY AMOUNTS BILLED BY THE NON-NETWORK PROVIDER FOR EMERGENCY AMBULANCE SERVICES THAT ARE IN EXCESS OF THE AMOUNT THAT HIGHMARK WV PAYS.
$250 per individual / $500 per family per calendar year
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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 Highmark Blue Cross Blue Shield: BlueCare Custom PPO Coverage for: Individual/Family
More informationHUMANA INSURANCE COMPANY:
HUMANA INSURANCE COMPANY: Humana Local Preferred Silver 4600/6300 Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage
More information$100 individual/$300 family. Copayments and coinsurance amounts don t count toward the deductible.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Highmark Blue Shield: Classic Blue Coverage for: Individual/Family Plan
More informationHUMANA INSURANCE COMPANY:
HUMANA INSURANCE COMPANY: Humana Local Preferred Silver 4600/6300 Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services EMI Health: Tx 5000
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services EMI Health: Tx 5000 Coverage Period: 01/01/2019-12/31/2019 Coverage for: Employee + Dependents Plan Type: PPO
More informationNetwork: Individual $0 / Family $0. Out of Network: Individual $1,500 / Family $3,000. Are there services covered before you meet your deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Independence Blue Cross: PPO Coverage for: Individual/Family Plan Type:
More informationlimit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
3M Choice Advantage Plan Coverage Period: Beginning on or after 01-01-2013 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: Single and family coverage Plan Type: HSA
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Small Group Benefit Comparison effective January 1, 2015 A guide to choosing the right plan for your business We re Proud to Be a Top 100 Health Plan 1 At Sharp Health Plan, we believe in making life better.
More informationImportant Questions Answers Why this Matters: For in-network providers, $2,600 individual / $5,000 family For out-of-network providers,
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 1-855-255-9952. Important Questions
More informationThis 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
Vincennes University: Blue Access (PPO) Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This
More informationAnthem Blue Cross and Blue Shield East Central College Lumenos HSA Blue Access Choice and Blue Preferred Select 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 or by calling 1-800-490-6145. Important Questions
More informationa) $4,000, per contract year b) $8,000, per contract year c) Yes
Consumer Driven Health Plan (CDHP), DENVER PUBLIC SCHOOLS, Group # 00100 Denver/Boulder Large Group PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Health Maintenance Organization (HMO) 2. OUT-OF-NETWORK CARE
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 Highmark Blue Cross Blue Shield: PPO Blue $1000 Coverage for: Individual/Family
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: 0411/01/ /31/2018
Summary of Benefits and Coverage: What this Plan Covers & What You For Covered Services Insert Issuer name here : 2-Tier SBC Sample Template - Alliance Select PCP CopayWashington County HDHP PPO 2018 -
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018-06/30/2019 Allegheny County Schools Health Insurance Consortium: Community Blue Flex
More information$0 See the chart starting on page 2 for your 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.chpstudent.com or by calling 1-800-633-7867. Important
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 UMR: MARINETTE COUNTY: 76-440038 011, 012, PLAN B Coverage for: Individual
More informationImportant 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 1-888-224-4902. Important Questions
More informationAnthem Blue Cross and Blue Shield East Central College Blue Access Choice PPO and Blue Preferred Select - Base Plan
plan pays different kinds of providers. 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
More informationYou don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Blue Care Elect Preferred 80 Copay Le Cordon Bleu Students Coverage Period: 2016-2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type:
More informationImportant Questions Answers Why this Matters: What is the overall deductible?
Verizon HCN 815: Anthem BCBS Coverage Period: 01/01/2013 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: You/You + Dependent(s) Plan Type: PPO This is only
More informationCoverage for: Individual + Family Plan Type: NPOS-HDHP
SBC01489W050320171146KYEQ0019 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 07/01/2017 HUMANA HEALTH PLAN, INC.: KY
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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.anthem.com or by calling 1-800-542-9402. Important Questions
More informationImportant 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
More informationSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services MN Applause Gold Copay
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2017-06/30/2018 LCIC Penn College of Technology: QHDHP PPO Coverage for: Individual/Family Plan Type: PPO
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More information01/01/ /31/2019 UMR: WAICU BENEFITS CONSORTIUM INC:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 12/31/2019 UMR: WAICU BENEFITS CONSORTIUM INC: 7670-00-010659 Standard Silver Coverage
More informationHighmark Blue Cross Blue Shield: BLUECARE CUSTOM PPO EXP 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.highmarkbcbs.com or by calling 1-800-241-5704. Important
More informationYou don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 Highmark Blue Cross Blue Shield: Affordablue $500/$1500/$4000 Coverage
More information$300/Individual or $700/family. What is the overall deductible?
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 MOE: Retiree-only Coverage for: Individual + Family Plan Type: PPO The
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