Virginia Plan Guide. for the individual market. Effective January 1, 2014
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- Todd Fowler
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1 Virginia Plan Guide for the individual market Effective January 1, 2014 This brochure is intended for broker use only and should not be distributed to consumers or employer groups VABENAHK Rev. 11/13
2 On-Exchange Plans Bronze DirectAccess with HSA cacd (ORUS) Bronze DirectAccess cabw (ORUQ) Bronze DirectAccess with Child Dental cdbw (ORV2) Bronze DirectAccess caam (ORUL) Network Name Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $3,750 $4,500 $4,500 $5,500 $6,200 $6,350 $6,350 $6,350 Coinsurance 25% 35% 35% 25% Office Visit: PCP Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) and and $40 copay per visit for first 2 office visits, then deductible and Preventive Care No cost to you No cost to you No cost to you No cost to you Urgent Care Emergency Room Care 45% coinsurance applies 45% coinsurance applies Inpatient Admission 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) Outpatient Surgery Hospital Facility 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) RX Tier 1 (Retail) RX Tier 2 (Retail) RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy deductible then 25% (tier 1) deductible then 35% (tier 1) deductible then 35% (tier 1) deductible then 25% (tier 1) * Costs may vary by site of service
3 2 Bronze DirectAccess with HSA caas (ORUN) Silver DirectAccess cbky (ORVM) Silver DirectAccess cbjs (ORVG) Silver DirectAccess cbfs (ORVB) Silver DirectAccess cbau (ORV6) Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital $6,000 $1,500 $2,250 $2,600 $3,350 $6,350 $5,500 $6,350 $6,000 $5,500 15% 30% 20% 20% 15% and $35 copay, unlimited and $45 copay, unlimited 3 No cost to you No cost to you No cost to you No cost to you No cost to you deductible then % (tier 1) 30% (tier 1) 3 20% (tier 1) 20% (tier 1) 3 20% (tier 1) 20% (tier 1) 15% (tier 1) or 45% (tier 2) coinsurance 15% (tier 1) or 45% (tier 2) coinsurance $15 copay $15 copay $15 copay $15 copay $40 copay $40 copay $40 copay $40 copay 3 3 deductible then 30% (tier 1) deductible then 15% (tier 1) or 45% (tier 2) coinsurance
4 On-Exchange Plans Gold DirectAccess ccam (ORWC) Gold DirectAccess with Child Dental cdda (ORWG) Catastrophic DirectAccess (ORWL) Network Name Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $750 $750 $6,350 $3,500 $3,500 $6,350 Coinsurance 20% 20% 0% Office Visit: PCP $30 copay, unlimited $30 copay, unlimited Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) $40 copay per visit for first and Preventive Care No cost to you No cost to you No cost to you Urgent Care Emergency Room Care Inpatient Admission Outpatient Surgery Hospital Facility 30% coinsurance apply 20% (tier 1) 20% (tier 1) 30% coinsurance apply 20% (tier 1) 20% (tier 1) RX Tier 1 (Retail) $15 copay $15 copay RX Tier 2 (Retail) $40 copay $40 copay RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy deductible then * Costs may vary by site of service
5 Notes 4
6 Off-Exchange Plans Core DirectAccess with HSA cacd (ORUT) Core DirectAccess cabw (ORUR) Core DirectAccess with Child Dental cdbw (ORV3) Core DirectAccess caam (ORUM) Network Name Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $3,750 $4,500 $4,500 $5,500 $6,200 $6,350 $6,350 $6,350 Coinsurance 25% 35% 35% 25% Office Visit: PCP Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) and and $40 copay per visit for first 2 office visits, then deductible and Preventive Care No cost to you No cost to you No cost to you No cost to you Urgent Care Emergency Room Care 45% coinsurance applies 45% coinsurance applies Inpatient Admission 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) Outpatient Surgery Hospital Facility 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) RX Tier 1 (Retail) RX Tier 2 (Retail) RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity deductible then 25% (tier 1) deductible then 35% (tier 1) deductible then 35% (tier 1) deductible then 25% (tier 1) Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy * Costs may vary by site of service
7 6 Core DirectAccess with HSA caas (ORUP) Essential DirectAccess cbky (ORVN) Essential DirectAccess cbjs (ORVH) Essential DirectAccess cbfs (ORVC) Essential DirectAccess cbau (ORV7) Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital $6,000 $1,500 $2,250 $2,600 $3,350 $6,350 $5,500 $6,350 $6,000 $5,500 15% 30% 20% 20% 15% and $35 copay, unlimited and $45 copay, unlimited 3 No cost to you No cost to you No cost to you No cost to you No cost to you deductible then % (tier 1) 30% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 15% coinsurance apply 15% (tier 1) or 45% (tier 2) coinsurance 15% (tier 1) or 45% (tier 2) coinsurance $15 copay $15 copay $15 copay $15 copay $40 copay $40 copay $40 copay $40 copay 3 3 deductible then 30% (tier 1) deductible then 15% (tier 1) or 45% (tier 2) coinsurance
8 Off-Exchange Plans Preferred DirectAccess ccam (ORWD) Preferred DirectAccess with Child Dental cdda (ORWH) Catastrophic DirectAccess (ORWM) Network Name Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $750 $750 $6,350 $3,500 $3,500 $6,350 Coinsurance 20% 20% 0% Office Visit: PCP $30 copay, unlimited $30 copay, unlimited Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) $40 copay per visit for first and Preventive Care No cost to you No cost to you No cost to you Urgent Care Emergency Room Care Inpatient Admission Outpatient Surgery Hospital Facility 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) RX Tier 1 (Retail) $15 copay $15 copay RX Tier 2 (Retail) $40 copay $40 copay RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy * Costs may vary by site of service deductible then
9 Notes 8
10 Exclusions and Limitations Exclusions This list includes some of the more common services not covered by these plans: Acupuncture Allergy tests and treatment, except as spelled out in your Evidence of Coverage Artificial insemination, fertilization, infertility drugs or sterilization reversal Artificial and mechanical hearts Alternative or complementary medicine Bariatric surgery, unless optional benefit rider has been purchased Benefits covered by Medicare or a governmental program Breast reduction or augmentation mammoplasty is excluded unless associated with breast reconstruction surgery following a medically necessary mastectomy resulting from cancer Care provided by a member of your family Care received in an emergency room that is not emergency care, except as specified in your Evidence of Coverage Charges incurred prior to the effective date of coverage or after the termination date of coverage Charges greater than the maximum allowable amount (charges exceeding the amount HealthKeepers recognizes for services) Comfort and/or convenience items Cosmetic surgery and/or treatment that s primarily intended to improve your appearance Custodial care Dental, except as described in your Evidence of Coverage Educational services, except as mandated Experimental or investigative treatment Non-chemical additions such as gambling, spending, religious Nutritional and dietary supplements Over-the-counter drugs, devices or products Pharmacy except as spelled out in your Evidence of Coverage Routine foot care Sclerotherapy (a medical procedure used to eliminate varicose veins and spider veins) Services we determine aren t medically necessary Sex transformation surgery TMJ and Craniomandibular Joint Disorder. Covered services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings) or prosthetics (crown, bridges, dentures). Vision except as described in your Evidence of Coverage Weight loss programs or treatment of obesity except as mandated Workers compensation Limitations These services are limited as described below: Therapy services Physical/Occupational therapy 30 combined visits per member per year Speech therapy 30 visits per member per year Chiropractic 30 visits for manipulation per member per year Home health care 100 visits per member per year Private duty nursing provided in a home care setting 16 hours per member per year Skilled nursing facility 100 days per stay *All plans available with optional bariatric surgery coverage for an additional premium. Preventive care services consist of services recommended by the United States Preventive Services Task Force, including well-child care, immunizations, PSA screenings, Pap tests, mammograms and more.
11 Notes 10
12 This piece refers to Policy form #s VA_HMHS(1/14), VA_HMHS(1/14)ONHIX. Schedule of benefits forms VA_SB_BRZ_3750_ORUT_(1/14), VA_SB_BRZ_4500_ORUR_(1/14), VA_SB_BRZ_5500_0RUM_(1/14), VA_SB_BRZ_6000_0RUP_(1/14), VA_SB_SLV_1500_0RVN_(1/14), VA_SB_SLV_2250_0RVH_(1/14), VA_SB_SLV_2600_0RVC_(1/14), VA_SB_SLV_3350_0RV7_(1/14),VA_SB_GLD_750_0RWD_(1/14), VA_SB_GLD_750_PD_0RWH_(1/14), VA_SB_CAT_6350_0RWM_(1/14), VA_SB_BRZ_3750_0RUS_(1/14)_ONHIX, VA_SB_BRZ_4500_0RUQ_(1/14)_ONHIX, VA_SB_BRZ_4500_PD_0RV2_(1/14)_ONHIX, VA_SB_BRZ_5500_0RUL_(1/14)_ONHIX, VA_SB_BRZ_6000_0RUN_(1/14)_ONHIX, VA_SB_SLV_1500_0RVM_(1/14)_ONHIX, VA_SB_SLV_2250_0RVG_(1/14)_ONHIX, VA_SB_SLV_2600_0RVB_(1/14)_ONHIX, VA_SB_SLV_3350_0RV6_(1/14)_ONHIX, VA_SB_GLD_750_0RWC_(1/14)_ONHIX, VA_SB_GLD_750_PD_0RWG_(1/14)_ONHIX, VA_SB_CAT_6350_0RWL_(1/14)_ONHIX and rider form VA_Bariatric_(1/14). HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
$250 per individual / $500 per family per calendar year
Benefit Summary - Trinity Grand Rapids 3/1/2018 12/31/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations
Important 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 1-800-451-1527. Important Questions
Important 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 1-800-542-9402. Important Questions
Highmark Health Insurance Company: Alliance Flex Blue PPO 1000 ONX (Base Plan)
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.highmarkblueshield.com or by calling 1-888-510-1064.
Important Questions Answers Why this Matters: For All Providers: $3,000 individual / $6,000 family
Anthem Blue Cross Blue Shield Adams Construction Company: Lumenos HSA 238 Plan Coverage Period: 10/01/2013 09/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:
Plan Guide for the Individual Market
VIRGINIA Effective January 1, 2015 Plan Guide for the Individual Market Plans that offer choices and meet Affordable Care Act requirements This brochure is intended for broker use only and should not be
Important Questions Answers Why this Matters:
CEBCO: Union County Modified Plan 2 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
Highmark 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
Clergy Benefit Comparison Effective January 1, 2019
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Important 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 https://eoc.anthem.com/eocdps/fi or by calling 1-888-650-4047.
Maine's Choice Pemaquid Silver HMO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Maine Maine's Choice Pemaquid Silver 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: Individual + Family
Medical Mutual : Diocese of Toledo Standard Plan
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 MedMutual.com/SBC or by calling 800.540.2583. Important Questions
Important Questions Answers Why this Matters:
Anthem Blue Cross: Anthem Preferred DirectAccess - ccas Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family
Important 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/ca or by calling 1-855-333-5730. Important
Important 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 https://eoc.anthem.com/eocdps/aso by calling 1-800-582-6941.
Important 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/ca or by calling 1-855-333-5730. Important
Medical Mutual : PPO Plan 1
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 MedMutual.com/SBC or by calling 800.540.2583. Important Questions
THE CELTIC HEALTH PLAN. Celtic makes health insurance easy and worry free.
THE CELTIC HEALTH PLAN Celtic makes health insurance easy and worry free. CELTIC MAKES IT EASY For information at your fingertips, go to www.celtic-net.com: Find physicians and hospitals in your PPO network
Medtronic HRA Plan Coverage Period: Beginning on or after
Medtronic HRA Plan Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage Period: Beginning on or after 01-01-2016 Coverage for: All Coverage Levels Plan Type: HDHP This is only
The Jay School Corp. Plan C
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 1-800-295-4119 Important Questions
Summary 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 -
Lumenos HK HDHP: Henrico County General Government and and Public Schools Coverage Period: 01/01/ /31/2017 Summary of Benefits and Coverage:
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 1-800-582-6941. Important Questions
WVURC HIGHMARK BC/BS PLAN COMPARISON
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
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these 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 by contacting Human Resources. Important Questions Answers Why
You 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 Delaware: Shared Cost Blue EPO Gold 1000-2 Free PCP Visits Coverage
Important 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 1-800-451-1527. Important Questions
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Summary of Benefits and Coverage: What this Plan Covers & What You For Covered Services Washington County Plan A PPO 2018 Plan 1 Coverage Period: 11/01/2017 10/31/2018 Coverage for: Single & Family Plan
limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Medtronic BCBSMN PPO Plan Coverage Period: Beginning on or after 01-01-2016 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: Single and family coverage Plan Type: PPO
Important Questions Answers Why this Matters: In-network: $200/Individual; $400/Family Out-of-network: $1,000/Individual; $2,000/Family
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 https://eoc.anthem.com/eocdps/aso or by calling 1-800-451-1527.
You 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: 08/01/2018-07/31/2019 Highmark Blue Cross Blue Shield: PPO Coverage for: Individual/Family Plan
Important 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
Anthem Blue Cross Your Plan: Custom Lumenos HSA 2600/ /50 Embedded (LHSA500) Your Network: Prudent Buyer PPO
Anthem Blue Cross Your Plan: Custom Lumenos HSA 2600/5200 20/50 Embedded (LHSA500) Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the
Important 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 1-800-295-4119. Important Questions
You 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 Health Insurance Company: Shared Cost Blue PPO Bronze 7500 Coverage
$750 individual/$1,500 family enhanced value network. $2,250 individual/$4,500 family standard value network.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 Journey Health System: Community Blue Flex PPO Coverage for: Individual/Family
HUMANA 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
Important Questions Answers Why this Matters: $100 Member/$200 Family for PCP Benefit level. $250 Member/$500 Family for Self-Referred Benefit level.
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/meabt or by calling 1-800-527-7706. Important
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
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
Best Buy HSA PPO FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Massachusetts Best Buy HSA PPO 3100 - FLEX Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2018 03/31/2019 Coverage for: Individual +
Important Questions Answers Why this Matters:
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: POS This is only a summary. If you want more detail about your coverage and costs, you
Blue Choice Plan 2 Adobe Systems Incorporated
Blue Choice Plan 2 Adobe Systems Incorporated Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: on or after 01/01/2014 Coverage for: Individual and Family Plan Type:
ID Prefix XQW RDP RDP Annual Enrollment
ID Prefix XQW RDP RDP Annual Enrollment Employees who are not currently enrolled in a MIIP Employees who are not currently enrolled in a MIIP health insurance plan can NOT come on to this plan at health
Regence BlueCross BlueShield of Oregon: Preferred Coverage Period: 01/01/ /31/2016
Regence BlueCross BlueShield of Oregon: Preferred Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 12/31/2016 Coverage for: Individual & Eligible Family
Important Questions Answers Why this Matters: In-network: $4,100 person /
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.mhc.coop or by calling (855) 488-0622. Important Questions
HC Capital Group, Inc. Coverage Period: Beginning on or after 1/1/14 High Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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Spokane Regional Health District Comparison of Medical Benefits and Rates - Effective January 1, 2010
moloney + o'neill insurance, benefits, financial, life. Group Health RQ-23354 Insurance Brokers Consultants 818 West Riverside Ste 800 Spokane, WA 99201 Telephone (509) 324-3024 Fax (509) 324-9588 Cost
Important 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.mhc.coop or by calling (406) 447-9510. Important Questions
Anthem Blue Cross Blue Shield School City of Mishawaka BA PPO HSA Coverage Period: 11/01/ /31/2015 Summary of Benefits and Coverage:
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 1-800-280-7293 Important Questions
PreferredOne. Are there other deductibles for specific services? Is there an out-ofpocket. There are no other specific deductibles.
PEIP Advantage HSA Single Plan Cost Level 4 Coverage Period: Beginning on or after 1-01-2018 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: Single coverage only Plan
PreferredOne. Are there other deductibles for specific services? Is there an out-ofpocket. There are no other specific deductibles.
PEIP Advantage Plan Cost Level 3 Coverage Period: Beginning on or after 1-01-2016 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: Single and family coverage Plan Type:
Anthem 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
Important Questions Answers Why this Matters
This is only a summary. If you want more details about coverage and costs, you can get the complete terms in the policy or plan document at www. or by calling 1-888-322-2115. Important Questions Answers
Premium, balance-billed charges, and health care this plan doesn't cover.
Assurant Health Silver Plan 002: Time Ins. Co. Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO This is
Coverage for: Individual/Family Plan Type: PPO
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
HealthKeepers Anthem HealthKeepers 20/20/500 POS / $10/$30/$50 or 20% with $150 Ded Coverage Period: 11/01/ /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 1-855-333-5735. Important Questions
Important 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
Important 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/ca or by calling 1-800-574-2751. Important
You 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.
Virginia Isd #706 Coverage Period: Beginning on or after 09-01-2016 Summary of Benefits and Coverage: What this Plan covers & What it CostsCoverage for: Single and family coverage Plan Type: PPO This is
TRS-ActiveCare Plan Highlights
2018 2019 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 In-Network Level of Benefits1 Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per
Important 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 https://eoc.anthem.com/eocdps/aso or by calling 1-800-451-1527.
Primary care visit to treat an injury or illness 10% coinsurance 30% coinsurance. Specialist care visit 10% coinsurance 30% coinsurance
Anthem Blue Cross Life and Health Insurance Company Student Health Plan: Saint Mary s College of California Your Plan: Custom PPO 200/10 Your Network: Prudent Buyer PPO This summary of benefits is a brief
Anthem BlueCross BlueShield Premier Plus POS / Optional Maternity Coverage 20% Summary of Benefits and Coverage:
Anthem BlueCross BlueShield Premier Plus POS / Optional Maternity Coverage 20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For:
Even though you pay these expenses, they don t count toward the out-ofpocket limit.
Ohio Northern University: Blue Access (PPO) $500 Plan A Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan
You 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 WRC Senior Services: PPO Coverage for: Individual/Family Plan Type: PPO
HealthPartners. Are there other deductibles for specific services? Is there an out-ofpocket. There are no other specific deductibles.
PEIP Advantage HSA Single Plan Cost Level 1 Coverage Period: Beginning on or after 1-01-2014 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: Single coverage only Plan
Medical Mutual : Plan 1
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 MedMutual.com/SBC or by calling 800.362.4700. Important Questions
Important Questions Answers Why this Matters: $2,850 individual / $5,650. 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.cpaprotectplus.com/main/forms_other.php or by calling
Your Plan: 2019 Advantage PPO Plan (S828 and Z0KC) Your Network: Prudent Buyer PPO
Anthem Blue Cross Your Plan: 2019 Advantage PPO Plan (S828 and Z0KC) Your Network: Prudent Buyer PPO ACWA JPIA C00361 This summary of benefits is a brief outline of coverage, designed to help you with
Important 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/imshealth or by calling 1-877-403-4424. Important
Important Questions Answers Why this Matters:
Anthem BlueCross BlueShield Blue Access Choice PPO Option 16 / Rx Option AJ Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2014-06/30/2015 Coverage For:
Important 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/ca or by calling 1-800-227-3641. Important
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
Coverage Period: 01/01/2016 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family Plan Type: PPO This is only a summary. If you want
You 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 Highmark Blue Cross Blue Shield: my Direct Blue EPO 1000G Coverage for:
Important Questions Answers Why this Matters: For in-network providers AND out-of-network providers combined: $1,750 Individual; $4,250 Family
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 https://eoc.anthem.com/eocdps/aso by calling 1-800-582-6941.
You 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: HDHP PPO Blue Coverage for: Individual/Family
Anthem: Self-Funded PPO Plan Coverage Period: 01/01/ /31/2015
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 1-877-442-4686. Important Questions
You 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 Highmark Health Insurance Company: my Direct Blue Lehigh Valley EPO 7150S
Anthem BlueCross BlueShield Anthem Preferred DirectAccess gfha 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 1-855-333-5735. Important Questions
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
Anthem BlueCross BlueShield Premier Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family Plan Type: PPO This
Type of Care/Plan Benefits In-Network Out-of-Network Annual deductible None None Annual out-of-pocket
Prepared for Rochester City School District Effective: 01/01/2014 Plan Feature Highlights Annual deductible None None Annual out-of-pocket $3,400 in network N/A maximum (medical services only, does not
The HPHC Insurance Company High Deductible Health Plan (HDHP) with HSA
Massachusetts The HPHC Insurance Company High Deductible Health Plan (HDHP) with HSA Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018
Anthem Blue Cross University of California Student Health Insurance Plan (UC SHIP) Custom UC San Francisco
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions
You 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: 10/01/2018-09/30/2019 Highmark Blue Cross Blue Shield: Community Blue PPO Coverage for: Individual/Family
Alliance Select SM. Important Questions Answers Why this Matters: What is the overall deductible?
Alliance Select SM Coverage Period: 01/01/2016 12/31/2016 Coverage for: Single, Two-person & Family Plan Type: PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a
Blue Cross Blue Shield PPO2 Medical Plan CVS Caremark 10/20/30 Prescription Plan
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
Important Questions Answers Why this Matters: In-Network: $500 Individual $1,000 Family Out-of-Network:
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.healthscopebenefits.com or by calling 1-800-282-9150.
Anthem 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
Highmark Blue Shield: Flex Blue PPO 1000 a Community Blue Plan
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.highmarkblueshield.com or by calling 1-888-510-1084.
Highmark Blue Shield: Flex Blue PPO 4000 a Community Blue Plan
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.highmarkblueshield.com or by calling 1-888-510-1084.
limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
State of MN Advantage Consumer-Directed Health Plan, Family, Cost Level 1, HealthPartners Coverage Period: Beginning on or after 01-01-2013 Summary of Benefits and Coverage: What this Plan covers & What
Important Questions Answers Why this Matters: In-network: $500/Individual; $1,000/Family Out-of-network:
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 1-800-445-7490. Important Questions
CIS - Copay Plan A RX4 with Hearing Aids Coverage Period: 01/01/ /31/2016
CIS - Copay Plan A RX4 with Hearing Aids Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual & Eligible Family Plan Type:
WPAHS: Community Blue HDHP 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 Highmarkbcbs.com or by calling 1-800-472-1506. Important
You 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:
deductible? This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply.
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: Individual Plan Type: 3 Tier PPO Archdiocese of Kansas City
HUMANA INSURANCE Humana National Preferred Silver 4250/6250 Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage:
HUMANA INSURANCE Humana National Preferred Silver 4250/6250 Plan Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:
Educators Health Alliance Coverage Period: 09/01/ /31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more detail about
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
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.bcbsnc.com/members/itg or by calling 1-800-451-5278.
You 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
Highmark Health Insurance Company: Shared Cost Blue PPO 1500
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.highmarkblueshield.com or by calling 1-888-510-1064.