Benefit Details

Medical Plan Ratings
Member Experience Rating	Plan Administration Rating	Medical Quality Rating
Not Rated	Not Rated	Not Rated

Annual Deductible
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Combined
Combined Medical & Drug Deductible	Individual: $7,000 Family: $14,000	--	Individual: $14,000 Family: $28,000	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: $7,000 Family: $14,000	--	Individual: $20,000 Family: $40,000	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)	No Charge 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.
Imaging (CT/PET Scans, MRIs)	No Charge 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.
X-rays and Diagnostic Imaging	No Charge 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.
Specialist Visit	No Charge 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.
Laboratory Outpatient and Professional Services	No Charge 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.
Primary Care Visit to Treat an Injury or Illness	No Charge 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.

Prescription Drug Coverage
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Generic Drugs	No Charge 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.
Preferred Brand Drugs	No Charge 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.
Non-Preferred Brand Drugs	No Charge 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	No Charge 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.

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	No Charge 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 Room Services	No Charge after deductible	--	No Charge 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	No Charge after deductible	--	No Charge 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	No Charge 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 Rehabilitation Services	No Charge 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.

Hospitalization Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Inpatient Physician and Surgical Services	No Charge after deductible	--	50% Coinsurance after deductible	Explanation: This Includes labor and delivery, mental health, and substance use disorder professional fee.
Habilitation Services	No Charge 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.
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible	--	50% Coinsurance after deductible	Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Skilled Nursing Facility	No Charge after deductible	--	50% Coinsurance after deductible	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	No Charge 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.
Substance Abuse Disorder Inpatient Services	No Charge 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.

Maternity Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Delivery and All Inpatient Services for Maternity Care	No Charge 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.
Prenatal and Postnatal Care	No Charge	--	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.

Home Health Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Home Health Care Services	No Charge after deductible	--	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	No Charge 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.
Durable Medical Equipment	No Charge 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.
Routine Foot Care	No Charge 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.
Hospice Services	No Charge 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	No Charge 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	No Charge 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.
Acupuncture	No Charge 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.
Rehabilitative Speech Therapy	No Charge 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.
Rehabilitative Occupational and Rehabilitative Physical Therapy	No Charge 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.
Abortion for Which Public Funding is Prohibited	No Charge 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.
Allergy Testing	No Charge 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.
Chemotherapy	No Charge 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.
Diabetes Education	No Charge	--	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.
Dialysis	No Charge 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.
Infusion Therapy	No Charge 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	No Charge 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.
Radiation	No Charge 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.
Reconstructive Surgery	No Charge 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.
Transplant	No Charge 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.
Treatment for Temporomandibular Joint Disorders	No Charge 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.
Additional Benefits	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 0% after ded. Outpatient Services Office Visit: 0% after ded. Mental/Behavioral Health Inpatient Professional Fee: 0% after ded. Delivery and all Inpatient Services Professional Fee: 0% after ded. Substance Use Disorder Inpatient Professional Fee: 0% after ded. Emergency Room Professional Fee: 0% after ded.	--	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: 0% 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	--	10%	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%	--	50%	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%	--	30%	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%	--	50%	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	--	No Charge	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	No Charge	--	No Charge	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 OnExchange 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.

Rate and Benefit Disclaimer Notification! Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company.

Additionally, information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy contain the exact terms and conditions of coverage. Your grant of access to the rate and benefit summaries contained herein may not be relied upon as a guarantee of your eligibility or coverage under these benefit plans.

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Tobacco use may affect the total premium up to 50% increase. Our premium may not include the actual tobacco surcharge. The actual tobacco surcharge will be determined from your state exchange.

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Plan Details Overall Quality Rating: Not Rated

Bronze 60 HDHP PPO

Additional Plan Information