Steve Shorr Insurance
Steve Shorr
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Bronze 60 HDHP EnhancedCare PPO

 

Bronze 60 EnhancedCare PPO

 

Silver 70 Off Exchange CommunityCare HMO

 

Bronze 60 PureCare HSP

 

Silver Value EnhancedCare PPO

 

Bronze 60 PureCare One EPO

 

Silver 70 Off Exchange EnhancedCare PPO

 

Bronze 60 PPO

 

Silver 70 Off Exchange PureCare One EPO

 

Silver 70 PPO

 


Premium:

You Pay
$465.66/mo
 

Add to Cart
Expanded Bronze

Premium:

You Pay
$469.41/mo
 

Add to Cart
Bronze

Premium:

You Pay
$469.60/mo
 

Add to Cart
Silver

Premium:

You Pay
$490.63/mo
 

Add to Cart
Bronze

Premium:

You Pay
$559.53/mo
 

Add to Cart
Silver

Premium:

You Pay
$580.19/mo
 

Add to Cart
Bronze

Premium:

You Pay
$593.58/mo
 

Add to Cart
Silver

Premium:

You Pay
$684.86/mo
 

Add to Cart
Bronze

Premium:

You Pay
$772.29/mo
 

Add to Cart
Silver

Premium:

You Pay
$965.52/mo
 

Add to Cart
Silver
Annual DeductibleBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Medical DeductibleSee BrochureIndividual: $6,300 Family: $12,600Individual: $4,000 Family: $8,000Individual: $6,300 Family: $12,600Individual: $5,000 Family: $10,000Individual: $6,300 Family: $12,600Individual: $4,000 Family: $8,000Individual: $6,300 Family: $12,600Individual: $4,000 Family: $8,000Individual: $4,000 Family: $8,000
Drug Benefits DeductibleSee BrochureIndividual: $500 Family: $1,000Individual: $300 Family: $600Individual: $500 Family: $1,000Individual: $500 Family: $1,000Individual: $500 Family: $1,000Individual: $300 Family: $600Individual: $500 Family: $1,000Individual: $300 Family: $600Individual: $300 Family: $600
Combined Medical & Drug DeductibleIndividual: $6,900 Family: $13,800See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Annual Out-of-PocketBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: $6,900 Family: $13,800Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600Individual: $7,800 Family: $15,600
DentalBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Dental Check-Up for ChildrenNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Major Dental Care – Child50%50%$300$30050%50%50%50%50%50%
Basic Dental Care – Child20%20%$25$2520%20%20%20%20%20%
Orthodontia – Child50%50%$1,000$1,00050%50%50%50%50%50%
Emergency HealthBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Urgent Care Centers or FacilitiesNo Charge after deductible$65 Copay per Visit after Deductible$40 per Visit$65 Copay per Visit after Deductible$45$65 Copay per Visit after deductible$40$65 Copay per Visit after Deductible$40 per Visit$40
Emergency Room ServicesNo Charge after deductible40% Coinsurance after deductible$40040% Coinsurance after deductible$400 Copay with deductible40% Coinsurance after deductible$40040% Coinsurance after deductible$400$400
Emergency Transportation/AmbulanceNo Charge after deductible40% Coinsurance after deductible$25540% Coinsurance after deductible$250 Copay with deductible40% Coinsurance after deductible$25540% Coinsurance after deductible$255$250
Home Health CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Home Health Care ServicesNo Charge after deductible40% Coinsurance after deductible$4540% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible$4540% Coinsurance after deductible$45$45
Hospitalization ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Inpatient Physician and Surgical ServicesNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Habilitation ServicesNo Charge after deductible$65$40$65$45$65$40$65$40$40
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Skilled Nursing FacilityNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Substance Abuse Disorder Outpatient ServicesNo Charge after deductible$65 Copay with deductible$40$65 Copay with deductible$45$65 Copay with deductible$40$65 Copay with deductible$40$40
Substance Abuse Disorder Inpatient ServicesNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Maternity CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Delivery and All Inpatient Services for Maternity CareNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Prenatal and Postnatal CareNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Other ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Durable Medical EquipmentNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Routine Foot CareNo Charge after deductible$65 Copay with deductible$40$65 Copay with deductible$45$65 Copay with deductible$40$65 Copay with deductible$40$40
Hospice ServicesNo Charge after deductibleNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Bariatric SurgeryNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Mental/Behavioral Health Outpatient ServicesNo Charge after deductible$65 Copay with deductible$40$65 Copay with deductible$45$65 Copay with deductible$40$65 Copay with deductible$40$40
AcupunctureNo Charge after deductible$65 Copay after deductible$40$65 Copay after deductible$45$65 Copay after deductible$40$65 Copay after deductible$40$40
Rehabilitative Speech TherapyNo Charge after deductible$65$40$65$45$65$40$65$40$40
Rehabilitative Occupational and Rehabilitative Physical TherapyNo Charge after deductible$65$40$65$45$65$40$65$40$40
Abortion for Which Public Funding is ProhibitedNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Allergy TestingNo Charge after deductible$95 Copay after deductible$80$95 Copay after deductible$60$95 Copay after deductible$80$95 Copay after deductible$80$80
ChemotherapyNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Diabetes EducationNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
DialysisNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Infusion TherapyNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Prosthetic DevicesNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
RadiationNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Reconstructive SurgeryNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
TransplantNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Treatment for Temporomandibular Joint DisordersNo Charge after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible40% Coinsurance after deductible20% Coinsurance after deductible20% Coinsurance after deductible
Additional BenefitsOutpatient Facility Fee (e.g., Ambulatory Surgery Center): No Charge after ded.
Outpatient Services Office Visit: No Charge after ded.
Mental/Behavioral Health Inpatient Professional Fee: No Charge after ded.
Delivery and all Inpatient Services Professional Fee: No Charge after ded.
Substance Use Disorder Inpatient Professional Fee: No Charge after ded.
Emergency Room Professional Fee: No Charge after ded.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 40% after ded.
Outpatient Services Office Visit: 40% after ded.
Mental/Behavioral Health Inpatient Professional Fee: 40% after ded.
Delivery and all Inpatient Services Professional Fee: 40% after ded.
Substance Use Disorder Inpatient Professional Fee: 40% after ded.
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20%
Outpatient Services Office Visit: 20%
Mental/Behavioral Health Inpatient Professional Fee: 20%
Delivery and all Inpatient Services Professional Fee: 20%
Substance Use Disorder Inpatient Professional Fee: 20%
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 40% after ded.
Outpatient Services Office Visit: 40% after ded.
Mental/Behavioral Health Inpatient Professional Fee: 40% after ded.
Delivery and all Inpatient Services Professional Fee: 40% after ded.
Substance Use Disorder Inpatient Professional Fee: 40% after ded.
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 30% after ded.
Outpatient Services Office Visit: 30% after ded.
Mental/Behavioral Health Inpatient Professional Fee: 30% after ded.
Delivery and all Inpatient Services Professional Fee: 30% after ded.
Substance Use Disorder Inpatient Professional Fee: 30% after ded.
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 40% after ded.
Outpatient Services Office Visit: 40% after ded.
Mental/Behavioral Health Inpatient Professional Fee: 40% after ded.
Delivery and all Inpatient Services Professional Fee: 40% after ded.
Substance Use Disorder Inpatient Professional Fee: 40% after ded.
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20%
Outpatient Services Office Visit: 20%
Mental/Behavioral Health Inpatient Professional Fee: 20%
Delivery and all Inpatient Services Professional Fee: 20%
Substance Use Disorder Inpatient Professional Fee: 20%
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 40% after ded.
Outpatient Services Office Visit: 40% after ded.
Mental/Behavioral Health Inpatient Professional Fee: 40% after ded.
Delivery and all Inpatient Services Professional Fee: 40% after ded.
Substance Use Disorder Inpatient Professional Fee: 40% after ded.
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20%
Outpatient Services Office Visit: 20%
Mental/Behavioral Health Inpatient Professional Fee: 20%
Delivery and all Inpatient Services Professional Fee: 20%
Substance Use Disorder Inpatient Professional Fee: 20%
Emergency Room Professional Fee: No Charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20%
Outpatient Services Office Visit: 20%
Mental/Behavioral Health Inpatient Professional Fee: 20%
Delivery and all Inpatient Services Professional Fee: 20%
Substance Use Disorder Inpatient Professional Fee: 20%
Emergency Room Professional Fee: No Charge
Outpatient ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Outpatient Surgery Physician/Surgical ServicesNo Charge after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible30% Coinsurance after deductible40% Coinsurance after deductible20%40% Coinsurance after deductible20%20%
Outpatient Rehabilitation ServicesNo Charge after deductible$65$40$65$45$65$40$65$40$40
Prescription Drug CoverageBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Generic DrugsNo Charge after deductible$18 Copay after deductible$16 Copay after deductible$18 Copay after deductible$15$18 Copay after deductible$16 Copay after deductible$18 Copay after deductible$16 Copay after deductible$16 Copay after deductible
Preferred Brand DrugsNo Charge after deductible40% Coinsurance after deductible$60 Copay after deductible40% Coinsurance after deductible$55 Copay after deductible40% Coinsurance after deductible$60 Copay after deductible40% Coinsurance after deductible$60 Copay after deductible$60 Copay after deductible
Non-Preferred Brand DrugsNo Charge after deductible40% Coinsurance after deductible$90 Copay after deductible40% Coinsurance after deductible$85 Copay with deductible40% Coinsurance after deductible$90 Copay after deductible40% Coinsurance after deductible$90 Copay after deductible$90 Copay after deductible
Specialty Drugs No Charge after deductible40% Coinsurance after deductible, up to $50020% Coinsurance after deductible, up to $25040% Coinsurance after deductible, up to $50030% Coinsurance after deductible, up to $25040% Coinsurance after deductible, up to $50020% Coinsurance after deductible, up to $25040% Coinsurance after deductible, up to $50020% Coinsurance after deductible, up to $25020% Coinsurance after deductible, up to $250
Preventative CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Well Baby Visits and CareNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Preventive Care/Screening/ImmunizationNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Professional ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Other Practitioner Office Visit (Nurse, Physician Assistant)No Charge after deductible$65 Copay per Visit after Deductible$40$65 Copay per Visit after Deductible$45$65 Copay after deductible$40$65 Copay per Visit after Deductible$40$40
Imaging (CT/PET Scans, MRIs)No Charge after deductible40% Coinsurance after deductible$32540% Coinsurance after deductible$300 Copay with deductible40% Coinsurance after deductible$32540% Coinsurance after deductible$325$325
X-rays and Diagnostic ImagingNo Charge after deductible40% Coinsurance after deductible$8540% Coinsurance after deductible$7040% Coinsurance after deductible$8540% Coinsurance after deductible$85$85
Specialist VisitNo Charge after deductible$95 Copay per Visit after Deductible$80$95 Copay per Visit after Deductible$60$95 Copay after deductible$80$95 Copay per Visit after Deductible$80$80
Laboratory Outpatient and Professional ServicesNo Charge after deductible$40$40$40$35$40$40$40$40$40
Primary Care Visit to Treat an Injury or IllnessNo Charge after deductible$65 Copay per Visit after Deductible$40$65 Copay per Visit after Deductible$45$65 Copay with deductible$40$65 Copay per Visit after Deductible$40$40
VisionBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Routine Eye Exam for ChildrenNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
Eye Glasses for ChildrenNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge
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  • In Network
  • Out Of Network
  • Combined In/Out Network
  • Limitations and Exclusions
Remove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth NetRemove planHealth Net
Bronze 60 HDHP EnhancedCare PPO

 

Bronze 60 EnhancedCare PPO

 

Silver 70 Off Exchange CommunityCare HMO

 

Bronze 60 PureCare HSP

 

Silver Value EnhancedCare PPO

 

Bronze 60 PureCare One EPO

 

Silver 70 Off Exchange EnhancedCare PPO

 

Bronze 60 PPO

 

Silver 70 Off Exchange PureCare One EPO

 

Silver 70 PPO

 


Premium:

You Pay
$465.66/mo
 

Add to Cart
Expanded Bronze

Premium:

You Pay
$469.41/mo
 

Add to Cart
Bronze

Premium:

You Pay
$469.60/mo
 

Add to Cart
Silver

Premium:

You Pay
$490.63/mo
 

Add to Cart
Bronze

Premium:

You Pay
$559.53/mo
 

Add to Cart
Silver

Premium:

You Pay
$580.19/mo
 

Add to Cart
Bronze

Premium:

You Pay
$593.58/mo
 

Add to Cart
Silver

Premium:

You Pay
$684.86/mo
 

Add to Cart
Bronze

Premium:

You Pay
$772.29/mo
 

Add to Cart
Silver

Premium:

You Pay
$965.52/mo
 

Add to Cart
Silver
Annual DeductibleBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Medical DeductibleSee BrochureIndividual: $12,600 Family: $25,200Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: $10,000 Family: $20,000Individual: Not Applicable Family: Not ApplicableIndividual: $8,000 Family: $16,000Individual: $12,600 Family: $25,200Individual: Not Applicable Family: Not ApplicableIndividual: $8,000 Family: $16,000
Drug Benefits DeductibleSee BrochureIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Combined Medical & Drug DeductibleIndividual: $13,800 Family: $27,600See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Annual Out-of-PocketBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: $25,000 Family: $50,000Individual: $25,000 Family: $50,000Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: $25,000 Family: $50,000Individual: Not Applicable Family: Not ApplicableIndividual: $25,000 Family: $50,000Individual: $25,000 Family: $50,000Individual: Not Applicable Family: Not ApplicableIndividual: $25,000 Family: $50,000
DentalBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Dental Check-Up for ChildrenNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered10%Not Covered10%
Major Dental Care – ChildNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered50%Not Covered50%
Basic Dental Care – ChildNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered30%Not Covered30%
Orthodontia – ChildNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered50%Not Covered50%
Emergency HealthBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Urgent Care Centers or Facilities50% Coinsurance after deductible50% Coinsurance after deductible$40 per Visit$65 Copay per Visit after Deductible50% Coinsurance after deductible$65 Copay per Visit after deductible50% Coinsurance after deductible50% Coinsurance after deductible$40 per Visit50% Coinsurance after deductible
Emergency Room ServicesNo Charge after deductible40% Coinsurance after deductible$40040% Coinsurance after deductible$400 Copay with deductible40% Coinsurance after deductible$40040% Coinsurance after deductible$400$400
Emergency Transportation/AmbulanceNo Charge after deductible40% Coinsurance after deductible$25540% Coinsurance after deductible$250 Copay with deductible40% Coinsurance after deductible$25540% Coinsurance after deductible$255$250
Home Health CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Home Health Care ServicesNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Hospitalization ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Inpatient Physician and Surgical Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Habilitation ServicesNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Inpatient Hospital Services (e.g., Hospital Stay)50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Skilled Nursing Facility50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Maternity CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Delivery and All Inpatient Services for Maternity Care50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Prenatal and Postnatal Care50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Other ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Mental/Behavioral Health Inpatient Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Durable Medical EquipmentNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Routine Foot Care50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Hospice Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Bariatric SurgeryNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Mental/Behavioral Health Outpatient Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
AcupunctureNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Rehabilitative Speech TherapyNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Rehabilitative Occupational and Rehabilitative Physical TherapyNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Abortion for Which Public Funding is Prohibited50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Allergy Testing50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Chemotherapy50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Diabetes Education50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Dialysis50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Infusion TherapyNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Prosthetic Devices50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Radiation50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Reconstructive Surgery50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
TransplantNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Treatment for Temporomandibular Joint Disorders50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Additional BenefitsOutpatient 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: No Charge 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: No Charge
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: No Charge
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: No Charge
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: No Charge
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: No Charge
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: No Charge
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: No Charge
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: No Charge
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: No Charge
Outpatient ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Outpatient Surgery Physician/Surgical Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Outpatient Rehabilitation ServicesNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Prescription Drug CoverageBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Generic DrugsNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Preferred Brand DrugsNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Non-Preferred Brand DrugsNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Specialty Drugs Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Preventative CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Well Baby Visits and CareNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Preventive Care/Screening/ImmunizationNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Professional ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Other Practitioner Office Visit (Nurse, Physician Assistant)50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
X-rays and Diagnostic Imaging50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Specialist Visit50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Laboratory Outpatient and Professional Services50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness50% Coinsurance after deductible50% Coinsurance after deductibleNot CoveredNot Covered50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible50% Coinsurance after deductibleNot Covered50% Coinsurance after deductible
VisionBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Routine Eye Exam for ChildrenNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
Eye Glasses for ChildrenNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered
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Bronze 60 HDHP EnhancedCare PPO

 

Bronze 60 EnhancedCare PPO

 

Silver 70 Off Exchange CommunityCare HMO

 

Bronze 60 PureCare HSP

 

Silver Value EnhancedCare PPO

 

Bronze 60 PureCare One EPO

 

Silver 70 Off Exchange EnhancedCare PPO

 

Bronze 60 PPO

 

Silver 70 Off Exchange PureCare One EPO

 

Silver 70 PPO

 


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Expanded Bronze

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Bronze

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$469.60/mo
 

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Silver

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$490.63/mo
 

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Bronze

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$559.53/mo
 

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Silver

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Bronze

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$593.58/mo
 

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Silver

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Silver
Annual DeductibleBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Medical DeductibleSee BrochureIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Drug Benefits DeductibleSee BrochureIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Combined Medical & Drug DeductibleIndividual: Not Applicable Family: Not ApplicableSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Annual Out-of-PocketBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
DentalBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Dental Check-Up for ChildrenSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Major Dental Care – ChildSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Basic Dental Care – ChildSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Orthodontia – ChildSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Emergency HealthBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Urgent Care Centers or FacilitiesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Emergency Room ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Emergency Transportation/AmbulanceSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Home Health CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Home Health Care ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Hospitalization ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Inpatient Physician and Surgical ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Habilitation ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Inpatient Hospital Services (e.g., Hospital Stay)See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Skilled Nursing FacilitySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Substance Abuse Disorder Outpatient ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Substance Abuse Disorder Inpatient ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Maternity CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Delivery and All Inpatient Services for Maternity CareSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Prenatal and Postnatal CareSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Other ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Mental/Behavioral Health Inpatient ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Durable Medical EquipmentSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Routine Foot CareSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Hospice ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Bariatric SurgerySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Mental/Behavioral Health Outpatient ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
AcupunctureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Rehabilitative Speech TherapySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Rehabilitative Occupational and Rehabilitative Physical TherapySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Abortion for Which Public Funding is ProhibitedSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Allergy TestingSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
ChemotherapySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Diabetes EducationSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
DialysisSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Infusion TherapySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Prosthetic DevicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
RadiationSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Reconstructive SurgerySee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
TransplantSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Treatment for Temporomandibular Joint DisordersSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Additional BenefitsSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Outpatient ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Outpatient Surgery Physician/Surgical ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Outpatient Rehabilitation ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Prescription Drug CoverageBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Generic DrugsSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Preferred Brand DrugsSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Non-Preferred Brand DrugsSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Specialty Drugs See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Preventative CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Well Baby Visits and CareSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Preventive Care/Screening/ImmunizationSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Professional ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Other Practitioner Office Visit (Nurse, Physician Assistant)See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Imaging (CT/PET Scans, MRIs)See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
X-rays and Diagnostic ImagingSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Specialist VisitSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Laboratory Outpatient and Professional ServicesSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Primary Care Visit to Treat an Injury or IllnessSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
VisionBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Routine Eye Exam for ChildrenSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Eye Glasses for ChildrenSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
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Bronze 60 HDHP EnhancedCare PPO

 

Bronze 60 EnhancedCare PPO

 

Silver 70 Off Exchange CommunityCare HMO

 

Bronze 60 PureCare HSP

 

Silver Value EnhancedCare PPO

 

Bronze 60 PureCare One EPO

 

Silver 70 Off Exchange EnhancedCare PPO

 

Bronze 60 PPO

 

Silver 70 Off Exchange PureCare One EPO

 

Silver 70 PPO

 


Premium:

You Pay
$465.66/mo
 

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Expanded Bronze

Premium:

You Pay
$469.41/mo
 

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Bronze

Premium:

You Pay
$469.60/mo
 

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Silver

Premium:

You Pay
$490.63/mo
 

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Bronze

Premium:

You Pay
$559.53/mo
 

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Silver

Premium:

You Pay
$580.19/mo
 

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Bronze

Premium:

You Pay
$593.58/mo
 

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Silver

Premium:

You Pay
$684.86/mo
 

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Bronze

Premium:

You Pay
$772.29/mo
 

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Silver

Premium:

You Pay
$965.52/mo
 

Add to Cart
Silver
Annual DeductibleBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Medical DeductibleSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Drug Benefits DeductibleSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Combined Medical & Drug DeductibleSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
Annual Out-of-PocketBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Out of Pocket Max for Med and Drug EHB Benefits (Total)See BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee BrochureSee Brochure
DentalBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Dental Check-Up for ChildrenExplanation: 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.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.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.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.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.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.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.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.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.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 – ChildExplanation: 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.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.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.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.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.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.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.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.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.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 – ChildExplanation: 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.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.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.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.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.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.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.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.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.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 – ChildExplanation: 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.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.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.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.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.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.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.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.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.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 HealthBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Urgent Care Centers or FacilitiesExplanation: 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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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 ServicesExplanation: 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.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.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.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.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.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.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.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.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.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/AmbulanceExplanation: 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.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.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.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.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.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.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.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.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.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 CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Home Health Care ServicesLimit: 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.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.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.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.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.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.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.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.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.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.
Hospitalization ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Inpatient Physician and Surgical ServicesExplanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder professional facility fee. This is applicable to all plans.
Habilitation ServicesExplanation: 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.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.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.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.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.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.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.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.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.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)Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee. This is applicable to all plans.
Skilled Nursing FacilityLimit: 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.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.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.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.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.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.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.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.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.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 ServicesExplanation: 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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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 ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Delivery and All Inpatient Services for Maternity CareExplanation: 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.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.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.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.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.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.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.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.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.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 CareExplanation: 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.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.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.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.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.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.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.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.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.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 ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Mental/Behavioral Health Inpatient ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 EquipmentExplanation: 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.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.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.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.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.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.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.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.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.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 CareExplanation: 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.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.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.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.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.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.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.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.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.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 ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 SurgeryExplanation: 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.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.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.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.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.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.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.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.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.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 ServicesExplanation: 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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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.
AcupunctureExplanation: 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.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.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.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.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.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.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.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.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.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 TherapyExplanation: 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.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.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.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.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.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.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.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.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.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 TherapyExplanation: 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.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.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.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.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.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.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.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.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.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 ProhibitedExplanation: 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.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.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.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.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.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.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.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.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.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 TestingExplanation: 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.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.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.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.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.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.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.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.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.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.
ChemotherapyExplanation: 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.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.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.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.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.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.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.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.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.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 EducationExplanation: 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.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.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.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.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.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.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.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.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.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.
DialysisExplanation: 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.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.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.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.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.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.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.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.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.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 TherapyExplanation: 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.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.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.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.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.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.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.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.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.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 DevicesExplanation: 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.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.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.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.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.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.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.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.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.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.
RadiationExplanation: 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.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.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.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.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.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.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.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.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.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 SurgeryExplanation: 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.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.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.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.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.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.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.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.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.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.
TransplantExplanation: 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.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.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.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.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.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.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.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.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.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 DisordersExplanation: 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.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.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.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.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.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.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.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.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.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 BenefitsOutpatient 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Outpatient ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Outpatient Surgery Physician/Surgical ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 CoverageBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Generic DrugsExplanation: 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.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.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.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.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.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.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.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.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.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 DrugsExplanation: 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.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.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.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.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.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.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.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.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.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 DrugsExplanation: 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.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.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.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.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.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.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.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.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.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 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.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.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.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.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.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.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.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.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.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 CareBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Well Baby Visits and CareExplanation: 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.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.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.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.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.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.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.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.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.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/ImmunizationExplanation: 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.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.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.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.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.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.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.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.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.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.
Professional ServicesBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Other Practitioner Office Visit (Nurse, Physician Assistant)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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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)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.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.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.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.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.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.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.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.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.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 ImagingExplanation: 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.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.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.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.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.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.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.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.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.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 VisitExplanation: 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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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 ServicesExplanation: 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.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.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.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.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.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.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.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.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.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 IllnessExplanation: 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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.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.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.
VisionBronze 60 HDHP EnhancedCare PPOBronze 60 EnhancedCare PPOSilver 70 Off Exchange CommunityCare HMOBronze 60 PureCare HSPSilver Value EnhancedCare PPOBronze 60 PureCare One EPOSilver 70 Off Exchange EnhancedCare PPOBronze 60 PPOSilver 70 Off Exchange PureCare One EPOSilver 70 PPO
Routine Eye Exam for ChildrenExplanation: 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.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.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.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.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.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.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.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.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.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 ChildrenExplanation: 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.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.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.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.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.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.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.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.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.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.
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