Benefit Details

Annual Deductible
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Combined
Combined Medical & Drug Deductible	Individual: $3,500 Family: $7,000	--	Individual: Not Applicable Family: Not Applicable	Individual: Not Applicable Family: Not Applicable

Annual Out-of-Pocket
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Combined
Out of Pocket Max for Med and Drug EHB Benefits (Total)	Individual: $8,550 Family: $17,100	--	Individual: Not Applicable Family: Not Applicable	Individual: Not Applicable Family: Not Applicable

Professional Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Other Practitioner Office Visit (Nurse, Physician Assistant)	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Imaging (CT/PET Scans, MRIs)	$300	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
X-rays and Diagnostic Imaging	$50	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist Visit	$75	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Laboratory Outpatient and Professional Services	$50	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Primary Care Visit to Treat an Injury or Illness	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Coverage
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Generic Drugs	$15	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Preferred Brand Drugs	$50	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non-Preferred Brand Drugs	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs	50% Coinsurance after deductible, up to $250	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Preventative Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Well Baby Visits and Care	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Preventive Care/Screening/Immunization	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Emergency Health
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Urgent Care Centers or Facilities	$75	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Emergency Room Services	50% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Emergency Transportation/Ambulance	50% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Outpatient Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Outpatient Surgery Physician/Surgical Services	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Outpatient Rehabilitation Services	$80	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Hospitalization Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Inpatient Physician and Surgical Services	50% Coinsurance after deductible	--	Not Covered	Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.
Habilitation Services	$80	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Inpatient Hospital Services (e.g., Hospital Stay)	50% Coinsurance after deductible	--	Not Covered	Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Skilled Nursing Facility	50% Coinsurance after deductible	--	Not Covered	Limit: 100 Days per Benefit Period Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Substance Abuse Disorder Outpatient Services	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Substance Abuse Disorder Inpatient Services	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Delivery and All Inpatient Services for Maternity Care	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Prenatal and Postnatal Care	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Home Health Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Home Health Care Services	$75	--	Not Covered	Limit: 100 Visit(s) per Year Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Other Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Mental/Behavioral Health Inpatient Services	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Durable Medical Equipment	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Routine Foot Care	$75	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Hospice Services	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Bariatric Surgery	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Mental/Behavioral Health Outpatient Services	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Acupuncture	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Rehabilitative Speech Therapy	$80	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Rehabilitative Occupational and Rehabilitative Physical Therapy	$80	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Abortion for Which Public Funding is Prohibited	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Allergy Testing	$50	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Chemotherapy	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Diabetes Education	$30	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Dialysis	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Infusion Therapy	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Prosthetic Devices	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Radiation	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Reconstructive Surgery	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Transplant	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Treatment for Temporomandibular Joint Disorders	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Additional Benefits	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 50% after ded. Outpatient Services Office Visit: 50% after ded. Mental/Behavioral Health Inpatient Professional Fee: 50% after ded. Delivery and all Inpatient Services Professional Fee: 50% after ded. Substance Use Disorder Inpatient Professional Fee: 50% after ded. Emergency Room Professional Fee: 50% after ded.	--	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Not Covered Outpatient Services Office Visit: Not Covered Mental/Behavioral Health Inpatient Professional Fee: Not Covered Delivery and all Inpatient Services Professional Fee: Not Covered Substance Use Disorder Inpatient Professional Fee: Not Covered Emergency Room Professional Fee: 50% after ded.	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Outpatient Services Office Visit: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Mental/Behavioral Health Inpatient Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Delivery and all Inpatient Services Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Substance Use Disorder Inpatient Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Emergency Room Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Dental
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Dental Check-Up for Children	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Major Dental Care – Child	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Basic Dental Care – Child	20% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Orthodontia – Child	50% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Routine Eye Exam for Children	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Eye Glasses for Children	50%	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Additional Plan Information

NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the Health plan's underwriting guidelines.

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

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Plan Details

Silver Simple Select EPO

Additional Plan Information