HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (7)Appendix A
Colorado Health Plan Description Form
PacifiCare Health Plan Administrators, Inc.
Name of Carrier
City of Fort Collins PPO Plan #9
Name of Plan
The format of this document is based on a format mandated for commercial plans by the State of Colorado.
PART A: TYPE OF COVERAGE
1. TYPE OF PLAN Self -Funded PPO plan.
2. OUT -OF -NETWORK Yes, but member pays more for out -of -network care.
CARE COVERED?'
3. AREAS OF COLORADO Plan is available only in the following counties: Adams, Arapahoe, Baca, Bent,
WHERE PLAN IS Boulder, Cheyenne, Clear Creek, Crowley, Custer, Delta, Denver, Dolores,
AVAILABLE Douglas, El Paso, Elbert, Fremont, Garfield, Gilpin, Grand, Huerfano, Jefferson,
Kiowa, Kit Carson, Lake, Larimer, Las Animas, Lincoln, Logan, Mesa,
Montezuma, Morgan, Otero, Ouray, Park, Phillips, Prowers, Pueblo, Rio Blanco,
Routt, Sedgwick, Summit, Teller, Washington, Weld, Yuma.
PART B: SUMMARY OF BENEFITS
Important Note: This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the
plan booklet, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain
treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan
procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified
providers or facilities). Consult the actual plan booklet to determine the exact terms and conditions of coverage. Ask your plan
administrator for a copy.
IN -NETWORK
OUT -OF -NETWORK
4. ANNUAL DEDUCTIBLE
Deductible applies unless otherwise
Deductible applies unless
noted.
otherwise noted.
a) Individual
$500
$500
b) Family
$1,500
$1,500
5. ENROLLEE OUT-OF-POCKET
The out-of-pocket maximums exclude
The out-of-pocket
ANNUAL MAXIMUMZ
deductibles and copayments.
maximums exclude
deductibles and copayments.
a) Individual
$1,000
$3,000 maximum
b) Family
$2,000
$6,000 maximum
These maximums could be
up to $5,000 individual and
$10,000 family when certain
benefits are paid at 50%.
' "Network" refers to a specified group of physicians, hospitals, medical clinics and other health care providers that your plan may require
you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it pays more of
your bill if you use their network providers (i.e., go in -network) than if you don't (i.e., go out -of -network).
z Out-of-pocket maximum. The maximum amount you will have to pay for allowable covered expenses under a health plan, which may or
may not include the deductible or copayments, depending on the contract for that plan.