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COB (Coordination of Benefits) Plan Option


Providing COB coverage, the Blue Cross Prudent Buyer or Arizona Foundation for Medical Care (depending on wich network you chose at open enrollment) provider newtworks reward insureds for utilizing in-network services.  A unique plan design for employees who are covered under their spouses benefits as well as their own (dual coverage). The plan is most beneficial if you have children and have coverage under your spouse, who's birthday is first in the year.  This plan has no deductible and reimburses benefits at 30% of usual, customary and reasonable charges (UCR).

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2007 Preferred Drug List

          - English

          - Spanish

BENEFITS
NETWORK
NON NETWORK

Lifetime Maximum Coverage Amount:

$5,000,000

Out of Pocket Calendar Year Maximum:

N/A

Calendar Year Deductible (individual/family):

No Deductible for Individual or Family

Office Visit:

30%

Emergency Room Co-payment:

None

Coinsurance:

30%

Hospitalization (facility and practitioner):

30%

Routine Annual Physical Exams:

None

Mammograms (Age 35+) & Well Woman Exams:

30%

Lab Fees:

30%

Pregnancy:

See Office Visits and Hospitalization

Well Child Care (to age 16):

See Office Visits and Lab Fees

Family Planning:

No Benefits

Psychiatric/Mental Health, Alcohol, Drug Dependency:

Covered under The Holman Group

Therapies (Speech, Respiratory, Occupational, Physical, Chiropractic):

30%

Emergency Ambulance Services:

Co-Insurance

30%

Local Ambulance Transportation

30% - $2000 Annual Maximum

Life Threatening Air Ambulance

30% - $18,000 Annual Maximum

Durable Medical Equipment Coverage:

30% - $4,000 Annual Maximum

Prescription Drugs:

Deductible

None

Generic

$5

Brand Name

$20

Non Preferred

$35

last updated: 2.8.10 jll

 



HUB International Insurance Services Inc
ICSVEBA Trust Benefits
Consultant & Administrator
1331 Morena Blvd. ,
Suite 300
San Diego, CA 92110
Phone: 1.619.275-6191
Toll: 1.866.833.8614
Fax: 1.619.275.6530
E-mail: aira.kato@
hubinternational.com
or

jennifer.lawson@hubinternational.com

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