v15.069512MOIndividualNo

Primary Care Visit to Treat an Injury or IllnessYesCoveredCost share applies to both in-person and telemedicine services.NoYesSpecialist VisitYesCoveredCost share applies to both in-person and telemedicine services.NoYesOther Practitioner Office Visit (Nurse, Physician Assistant)YesCoveredNoYesOutpatient Facility Fee (e.g., Ambulatory Surgery Center)YesCoveredNoYesOutpatient Surgery Physician/Surgical ServicesYesCoveredNoYesHospice ServicesYesCoveredNoYesRoutine Dental Services (Adult)Not CoveredInfertility TreatmentNot CoveredLong-Term/Custodial Nursing Home CareNot CoveredPrivate-Duty NursingYesCoveredYes82Visit(s) per Benefit PeriodPrivate Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit.NoYesRoutine Eye Exam (Adult)Not CoveredUrgent Care Centers or FacilitiesYesCoveredVirtual urgent care services provided by Oscar-designated virtual care providers are covered in full.NoYesHome Health Care ServicesYesCoveredYes100Visit(s) per Benefit PeriodTo be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basisNoYesEmergency Room ServicesYesCoveredNoYesEmergency Transportation/AmbulanceYesCoveredNoYesInpatient Hospital Services (e.g., Hospital Stay)YesCoveredNoYesInpatient Physician and Surgical ServicesYesCoveredNoYesBariatric SurgeryNot CoveredCosmetic SurgeryNot CoveredSkilled Nursing FacilityYesCoveredYes150Days per Benefit PeriodLimit includes rehab and outpatient day rehab.NoYesPrenatal and Postnatal CareYesCoveredNoYesDelivery and All Inpatient Services for Maternity CareYesCoveredNoYesMental/Behavioral Health Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesMental/Behavioral Health Inpatient ServicesYesCoveredNoYesSubstance Abuse Disorder Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesSubstance Abuse Disorder Inpatient ServicesYesCoveredNoYesGeneric DrugsYesCoveredNoYesPreferred Brand DrugsYesCoveredNoYesNon-Preferred Brand DrugsYesCoveredNoYesSpecialty DrugsYesCoveredNoYesOutpatient Rehabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodTo be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.NoYesHabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodABA for autism only covered through age 18.Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living." 20 Visit(s) per Benefit Period (Outpatient 20 visits per Benefit Period per therapy for physical and occupational therapies)NoYesChiropractic CareYesCoveredChiropractic visits beyond 26 per benefit period require Prior AuthorizationNoYesDurable Medical EquipmentYesCoveredNon-Medically Necessary enhancements to standard equipment and devices.NoYesHearing AidsYesCoveredBenefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.NoYesImaging (CT/PET Scans, MRIs)YesCoveredNoYesPreventive Care/Screening/ImmunizationYesCoveredNoYesRoutine Foot CareYesCoveredCoverage is only available if Medically NecessaryCoverage is available if Medically Necessary.NoYesAcupunctureNot CoveredWeight Loss ProgramsNot CoveredRoutine Eye Exam for ChildrenYesCoveredYes1Exam(s) per Benefit PeriodNoYesEye Glasses for ChildrenYesCoveredYes1Item(s) per YearCovered lenses and frames each available at limit of one per yearNoYesDental Check-Up for ChildrenYesNot CoveredDental Only Plan AvailableRehabilitative Speech TherapyYesCoveredUnlimited visits for speech therapy.NoYesRehabilitative Occupational and Rehabilitative Physical TherapyYesCoveredYes20Visit(s) per Benefit Period20 visit limit each for PT and OT.NoYesWell Baby Visits and CareYesCoveredNoYesLaboratory Outpatient and Professional ServicesYesCoveredNoYesX-rays and Diagnostic ImagingYesCoveredNoYesBasic Dental Care - ChildYesNot CoveredDental Only Plan AvailableOrthodontia - ChildYesNot CoveredDental Only Plan AvailableMajor Dental Care - ChildYesNot CoveredDental Only Plan AvailableBasic Dental Care - AdultNot CoveredOrthodontia - AdultNot CoveredMajor Dental Care - AdultNot CoveredAbortion for Which Public Funding is ProhibitedNot CoveredTransplantYesCoveredNoYesAccidental DentalYesCoveredYes3000Dollars per EpisodeTreatment must begin within 12 months of the injuryNoYesDialysisYesCoveredCovered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysisNoYesAllergy TestingYesCoveredNoYesChemotherapyYesCoveredNoYesRadiationYesCoveredNoYesDiabetes EducationYesCoveredNoYesProsthetic DevicesYesCoveredBenefits include the purchase, fitting, adjustments, repairs and replacementsNoYesInfusion TherapyYesCoveredNoYesTreatment for Temporomandibular Joint DisordersYesCoveredCovered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.NoYesNutritional CounselingYesCoveredNoYesReconstructive SurgeryYesCoveredBenefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.NoYes69512MO0010024Bronze Classic 470069512MO001MON001MOS001MOF001ExistingEPOExpanded BronzeNot ApplicableNoBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010024-00Bronze Classic 4700Expanded BronzeStandard Bronze Off Exchange PlanYesYesNoYes44%56%$4,700$200$2,800$0$4,200$700$0$0$2,200$400$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,800$9800 per person | $19600 per group$9,800$9800 per person | $19600 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$4,700$4700 per person | $9400 per group50.00%$4,700$4700 per person | $9400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.638047869059871Primary Care Visit to Treat an Injury or Illness$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010024-01Bronze Classic 4700Expanded BronzeStandard Bronze On Exchange PlanYesYesNoYes44%56%$4,700$200$2,800$0$4,200$700$0$0$2,200$400$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,800$9800 per person | $19600 per group$9,800$9800 per person | $19600 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$4,700$4700 per person | $9400 per group50.00%$4,700$4700 per person | $9400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.638047869059871Primary Care Visit to Treat an Injury or Illness$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010024-02AIAN Cost ShareExpanded BronzeZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010024-03Bronze Classic 4700Expanded BronzeLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,800$9800 per person | $19600 per group$9,800$9800 per person | $19600 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$4,700$4700 per person | $9400 per group50.00%$4,700$4700 per person | $9400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.638047869059871Primary Care Visit to Treat an Injury or Illness$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025Silver Simple PCP Saver69512MO001MON001MOS001MOF001ExistingEPOSilverNot ApplicableNoBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010025-00Silver Simple PCP SaverSilverStandard Silver Off Exchange PlanYesYesNoYes44%56%$5,750$0$2,200$0$100$2,300$0$0$2,200$200$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,100$5100 per person | $10200 per group40.00%$5,100$5100 per person | $10200 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.701349686305894Primary Care Visit to Treat an Injury or Illness$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025-01Silver Simple PCP SaverSilverStandard Silver On Exchange PlanYesYesNoYes44%56%$5,750$0$2,200$0$100$2,300$0$0$2,200$200$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,100$5100 per person | $10200 per group40.00%$5,100$5100 per person | $10200 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.701349686305894Primary Care Visit to Treat an Injury or Illness$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025-02AIAN Cost ShareSilverZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010025-03Silver Simple PCP SaverSilverLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,100$5100 per person | $10200 per group40.00%$5,100$5100 per person | $10200 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.701349686305894Primary Care Visit to Treat an Injury or Illness$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025-04Silver Simple PCP Saver CSR 250Silver73% AV Level Silver PlanYesYesNoYes44%56%$5,750$0$1,900$0$100$1,900$0$0$2,200$200$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$8,000$8000 per person | $16000 per group$8,000$8000 per person | $16000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$4,900$4900 per person | $9800 per group40.00%$4,900$4900 per person | $9800 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.732275281752868Primary Care Visit to Treat an Injury or Illness$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$20.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$70.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025-05Silver Simple PCP Saver CSR 200Silver87% AV Level Silver PlanYesYesNoYes44%56%$800$0$2,500$0$100$1,100$0$0$800$100$600$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$3,200$3200 per person | $6400 per group$3,200$3200 per person | $6400 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$800$800 per person | $1600 per group40.00%$800$800 per person | $1600 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.871021505194592Primary Care Visit to Treat an Injury or Illness$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010025-06Silver Simple PCP Saver CSR 150Silver94% AV Level Silver PlanYesYesNoYes44%56%$0$0$1,900$0$0$800$20$0$0$40$400$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$1,900$1900 per person | $3800 per group$1,900$1900 per person | $3800 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group20.00%$0$0 per person | $0 per group20.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.94044646324235Primary Care Visit to Treat an Injury or Illness$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Urgent Care Centers or Facilities$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable20.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable20.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Generic Drugs$0.00$5.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Rehabilitation Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Allergy Testing$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Nutritional Counseling$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%69512MO0010030Silver Elite Saver Plus69512MO001MON001MOS001MOF001ExistingEPOSilverNot ApplicableNoBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010030-00Silver Elite Saver PlusSilverStandard Silver Off Exchange PlanNoYesNoYes44%56%$0$500$5,000$0$0$3,000$0$0$0$500$1,100$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group50.00%$0$0 per person | $0 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$200$200 per person | $400 per group50.00%$200$200 per person | $400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.702816237244132Primary Care Visit to Treat an Injury or Illness$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Allergy Testing$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Nutritional Counseling$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%69512MO0010030-01Silver Elite Saver PlusSilverStandard Silver On Exchange PlanNoYesNoYes44%56%$0$500$5,000$0$0$3,000$0$0$0$500$1,100$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group50.00%$0$0 per person | $0 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$200$200 per person | $400 per group50.00%$200$200 per person | $400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.702816237244132Primary Care Visit to Treat an Injury or Illness$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Allergy Testing$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Nutritional Counseling$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%69512MO0010030-02AIAN Cost ShareSilverZero Cost Sharing Plan VariationNoYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010030-03Silver Elite Saver PlusSilverLimited Cost Sharing Plan VariationNoYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group50.00%$0$0 per person | $0 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$200$200 per person | $400 per group50.00%$200$200 per person | $400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.702816237244132Primary Care Visit to Treat an Injury or Illness$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$80.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Allergy Testing$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Nutritional Counseling$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%69512MO0010030-04Silver Elite Saver Plus CSR 250Silver73% AV Level Silver PlanNoYesNoYes44%56%$0$400$5,000$0$0$3,000$0$0$0$500$1,100$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$8,450$8450 per person | $16900 per group$8,450$8450 per person | $16900 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group50.00%$0$0 per person | $0 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$200$200 per person | $400 per group50.00%$200$200 per person | $400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.734944993653987Primary Care Visit to Treat an Injury or Illness$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable50.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$125.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Allergy Testing$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Nutritional Counseling$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%69512MO0010030-05Silver Elite Saver Plus CSR 200Silver87% AV Level Silver PlanNoYesNoYes44%56%$0$200$3,000$0$0$1,800$0$0$0$200$600$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$3,350$3350 per person | $6700 per group$3,350$3350 per person | $6700 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group30.00%$0$0 per person | $0 per group30.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$100$100 per person | $200 per group50.00%$100$100 per person | $200 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.871008034523071Primary Care Visit to Treat an Injury or Illness$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Urgent Care Centers or Facilities$15.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Allergy Testing$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Nutritional Counseling$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%69512MO0010030-06Silver Elite Saver Plus CSR 150Silver94% AV Level Silver PlanNoYesNoYes44%56%$0$60$1,800$0$0$800$0$0$0$40$400$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$1,900$1900 per person | $3800 per group$1,900$1900 per person | $3800 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableMedical EHB Deductible$0$0 per person | $0 per group20.00%$0$0 per person | $0 per group20.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableDrug EHB Deductible$50$50 per person | $100 per group50.00%$50$50 per person | $100 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.941110760437614Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Urgent Care Centers or Facilities$15.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable20.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable20.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Generic Drugs$0.00$5.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable20.00%Not Applicable100.00%69512MO0010064Gold Simple69512MO001MON001MOS001MOF001NewEPOGoldNot ApplicableNoBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010064-00Gold SimpleGoldStandard Gold Off Exchange PlanYesYesNoYes44%56%$3,500$300$1,300$0$3,500$500$0$0$2,100$200$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,950$9950 per person | $19900 per group$9,950$9950 per person | $19900 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$3,300$3300 per person | $6600 per group20.00%$3,300$3300 per person | $6600 per group20.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.780568677153387Primary Care Visit to Treat an Injury or Illness$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$65.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010064-01Gold SimpleGoldStandard Gold On Exchange PlanYesYesNoYes44%56%$3,500$300$1,300$0$3,500$500$0$0$2,100$200$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,950$9950 per person | $19900 per group$9,950$9950 per person | $19900 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$3,300$3300 per person | $6600 per group20.00%$3,300$3300 per person | $6600 per group20.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.780568677153387Primary Care Visit to Treat an Injury or Illness$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$65.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010064-02AIAN Cost ShareGoldZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010064-03Gold SimpleGoldLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,950$9950 per person | $19900 per group$9,950$9950 per person | $19900 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$3,300$3300 per person | $6600 per group20.00%$3,300$3300 per person | $6600 per group20.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.780568677153387Primary Care Visit to Treat an Injury or Illness$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable20.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$65.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$20.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable20.00% Coinsurance after deductibleNot Applicable100.00%

v15.069512MOIndividualNo

Primary Care Visit to Treat an Injury or IllnessYesCoveredFirst five (5) non-preventive visits are covered in full. Cost share applies to both in-person and telemedicine services.NoYesSpecialist VisitYesCoveredEndocrinology, diabetic eye exams, and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.NoYesOther Practitioner Office Visit (Nurse, Physician Assistant)YesCoveredNoYesOutpatient Facility Fee (e.g., Ambulatory Surgery Center)YesCoveredNoYesOutpatient Surgery Physician/Surgical ServicesYesCoveredNoYesHospice ServicesYesCoveredNoYesRoutine Dental Services (Adult)Not CoveredInfertility TreatmentNot CoveredLong-Term/Custodial Nursing Home CareNot CoveredPrivate-Duty NursingYesCoveredYes82Visit(s) per Benefit PeriodPrivate Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit.NoYesRoutine Eye Exam (Adult)Not CoveredUrgent Care Centers or FacilitiesYesCoveredVirtual urgent care services provided by Oscar-designated virtual care providers are covered in full.NoYesHome Health Care ServicesYesCoveredYes100Visit(s) per Benefit PeriodTo be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basisNoYesEmergency Room ServicesYesCoveredNoYesEmergency Transportation/AmbulanceYesCoveredNoYesInpatient Hospital Services (e.g., Hospital Stay)YesCoveredNoYesInpatient Physician and Surgical ServicesYesCoveredNoYesBariatric SurgeryNot CoveredCosmetic SurgeryNot CoveredSkilled Nursing FacilityYesCoveredYes150Days per Benefit PeriodLimit includes rehab and outpatient day rehab.NoYesPrenatal and Postnatal CareYesCoveredNoYesDelivery and All Inpatient Services for Maternity CareYesCoveredNoYesMental/Behavioral Health Outpatient ServicesYesCoveredFirst five (5) office visits combined between Outpatient Mental Health Services and Outpatient Chemical/Substance Use Disorder are covered in full. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesMental/Behavioral Health Inpatient ServicesYesCoveredNoYesSubstance Abuse Disorder Outpatient ServicesYesCoveredFirst five (5) office visits combined between Outpatient Mental Health Services and Outpatient Chemical/Substance Use Disorder are covered in full. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesSubstance Abuse Disorder Inpatient ServicesYesCoveredNoYesGeneric DrugsYesCoveredNoYesPreferred Brand DrugsYesCoveredNoYesNon-Preferred Brand DrugsYesCoveredNoYesSpecialty DrugsYesCoveredNoYesOutpatient Rehabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodTo be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.NoYesHabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodABA for autism only covered through age 18.Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living." 20 Visit(s) per Benefit Period (Outpatient 20 visits per Benefit Period per therapy for physical and occupational therapies)NoYesChiropractic CareYesCoveredChiropractic visits beyond 26 per benefit period require Prior AuthorizationNoYesDurable Medical EquipmentYesCoveredNon-Medically Necessary enhancements to standard equipment and devices.NoYesHearing AidsYesCoveredBenefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.NoYesImaging (CT/PET Scans, MRIs)YesCoveredNoYesPreventive Care/Screening/ImmunizationYesCoveredNoYesRoutine Foot CareYesCoveredCoverage is only available if Medically NecessaryCoverage is available if Medically Necessary.NoYesAcupunctureNot CoveredWeight Loss ProgramsNot CoveredRoutine Eye Exam for ChildrenYesCoveredYes1Exam(s) per Benefit PeriodNoYesEye Glasses for ChildrenYesCoveredYes1Item(s) per YearCovered lenses and frames each available at limit of one per yearNoYesDental Check-Up for ChildrenYesNot CoveredDental Only Plan AvailableRehabilitative Speech TherapyYesCoveredUnlimited visits for speech therapy.NoYesRehabilitative Occupational and Rehabilitative Physical TherapyYesCoveredYes20Visit(s) per Benefit Period20 visit limit each for PT and OT.NoYesWell Baby Visits and CareYesCoveredNoYesLaboratory Outpatient and Professional ServicesYesCoveredLabs (HbA1c screening, urinalysis, metabolic panel, lipid panel) are covered in full.NoYesX-rays and Diagnostic ImagingYesCoveredNoYesBasic Dental Care - ChildYesNot CoveredDental Only Plan AvailableOrthodontia - ChildYesNot CoveredDental Only Plan AvailableMajor Dental Care - ChildYesNot CoveredDental Only Plan AvailableBasic Dental Care - AdultNot CoveredOrthodontia - AdultNot CoveredMajor Dental Care - AdultNot CoveredAbortion for Which Public Funding is ProhibitedNot CoveredTransplantYesCoveredNoYesAccidental DentalYesCoveredYes3000Dollars per EpisodeTreatment must begin within 12 months of the injuryNoYesDialysisYesCoveredCovered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysisNoYesAllergy TestingYesCoveredNoYesChemotherapyYesCoveredNoYesRadiationYesCoveredNoYesDiabetes EducationYesCoveredNoYesProsthetic DevicesYesCoveredBenefits include the purchase, fitting, adjustments, repairs and replacementsNoYesInfusion TherapyYesCoveredNoYesTreatment for Temporomandibular Joint DisordersYesCoveredCovered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.NoYesNutritional CounselingYesCoveredNoYesReconstructive SurgeryYesCoveredBenefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.NoYes69512MO0010055Bronze Simple Diabetes69512MO001MON001MOS001MOF001NewEPOExpanded BronzeNot ApplicableYesBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010055-00Bronze Simple DiabetesExpanded BronzeStandard Bronze Off Exchange PlanYesYesNoYes44%56%$5,500$200$2,400$0$4,200$600$0$0$2,200$200$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,500$5500 per person | $11000 per group50.00%$5,500$5500 per person | $11000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.64684597344302164.82%5Primary Care Visit to Treat an Injury or Illness$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010055-01Bronze Simple DiabetesExpanded BronzeStandard Bronze On Exchange PlanYesYesNoYes44%56%$5,500$200$2,400$0$4,200$600$0$0$2,200$200$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,500$5500 per person | $11000 per group50.00%$5,500$5500 per person | $11000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.64684597344302164.82%5Primary Care Visit to Treat an Injury or Illness$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010055-02AIAN Cost ShareExpanded BronzeZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1100.00%5Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010055-03Bronze Simple DiabetesExpanded BronzeLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0YesMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,500$5500 per person | $11000 per group50.00%$5,500$5500 per person | $11000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.64684597344302164.82%5Primary Care Visit to Treat an Injury or Illness$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$200.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$50.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$30.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$150.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%

v15.069512MOIndividualNo

Primary Care Visit to Treat an Injury or IllnessYesCoveredCost share applies to both in-person and telemedicine services.NoYesSpecialist VisitYesCoveredEndocrinology, diabetic eye exams, and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.NoYesOther Practitioner Office Visit (Nurse, Physician Assistant)YesCoveredNoYesOutpatient Facility Fee (e.g., Ambulatory Surgery Center)YesCoveredNoYesOutpatient Surgery Physician/Surgical ServicesYesCoveredNoYesHospice ServicesYesCoveredNoYesRoutine Dental Services (Adult)Not CoveredInfertility TreatmentNot CoveredLong-Term/Custodial Nursing Home CareNot CoveredPrivate-Duty NursingYesCoveredYes82Visit(s) per Benefit PeriodPrivate Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit.NoYesRoutine Eye Exam (Adult)Not CoveredUrgent Care Centers or FacilitiesYesCoveredVirtual urgent care services provided by Oscar-designated virtual care providers are covered in full.NoYesHome Health Care ServicesYesCoveredYes100Visit(s) per Benefit PeriodTo be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basisNoYesEmergency Room ServicesYesCoveredNoYesEmergency Transportation/AmbulanceYesCoveredNoYesInpatient Hospital Services (e.g., Hospital Stay)YesCoveredNoYesInpatient Physician and Surgical ServicesYesCoveredNoYesBariatric SurgeryNot CoveredCosmetic SurgeryNot CoveredSkilled Nursing FacilityYesCoveredYes150Days per Benefit PeriodLimit includes rehab and outpatient day rehab.NoYesPrenatal and Postnatal CareYesCoveredNoYesDelivery and All Inpatient Services for Maternity CareYesCoveredNoYesMental/Behavioral Health Outpatient ServicesYesCoveredFirst five (5) office visits combined between Outpatient Mental Health Services and Outpatient Chemical/Substance Use Disorder are covered in full. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesMental/Behavioral Health Inpatient ServicesYesCoveredNoYesSubstance Abuse Disorder Outpatient ServicesYesCoveredFirst five (5) office visits combined between Outpatient Mental Health Services and Outpatient Chemical/Substance Use Disorder are covered in full. The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesSubstance Abuse Disorder Inpatient ServicesYesCoveredNoYesGeneric DrugsYesCoveredNoYesPreferred Brand DrugsYesCoveredNoYesNon-Preferred Brand DrugsYesCoveredNoYesSpecialty DrugsYesCoveredNoYesOutpatient Rehabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodTo be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.NoYesHabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodABA for autism only covered through age 18.Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living." 20 Visit(s) per Benefit Period (Outpatient 20 visits per Benefit Period per therapy for physical and occupational therapies)NoYesChiropractic CareYesCoveredChiropractic visits beyond 26 per benefit period require Prior AuthorizationNoYesDurable Medical EquipmentYesCoveredNon-Medically Necessary enhancements to standard equipment and devices.NoYesHearing AidsYesCoveredBenefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.NoYesImaging (CT/PET Scans, MRIs)YesCoveredNoYesPreventive Care/Screening/ImmunizationYesCoveredNoYesRoutine Foot CareYesCoveredCoverage is only available if Medically NecessaryCoverage is available if Medically Necessary.NoYesAcupunctureNot CoveredWeight Loss ProgramsNot CoveredRoutine Eye Exam for ChildrenYesCoveredYes1Exam(s) per Benefit PeriodNoYesEye Glasses for ChildrenYesCoveredYes1Item(s) per YearCovered lenses and frames each available at limit of one per yearNoYesDental Check-Up for ChildrenYesNot CoveredDental Only Plan AvailableRehabilitative Speech TherapyYesCoveredUnlimited visits for speech therapy.NoYesRehabilitative Occupational and Rehabilitative Physical TherapyYesCoveredYes20Visit(s) per Benefit Period20 visit limit each for PT and OT.NoYesWell Baby Visits and CareYesCoveredNoYesLaboratory Outpatient and Professional ServicesYesCoveredLabs (HbA1c screening, urinalysis, metabolic panel, lipid panel) are covered in full.NoYesX-rays and Diagnostic ImagingYesCoveredNoYesBasic Dental Care - ChildYesNot CoveredDental Only Plan AvailableOrthodontia - ChildYesNot CoveredDental Only Plan AvailableMajor Dental Care - ChildYesNot CoveredDental Only Plan AvailableBasic Dental Care - AdultNot CoveredOrthodontia - AdultNot CoveredMajor Dental Care - AdultNot CoveredAbortion for Which Public Funding is ProhibitedNot CoveredTransplantYesCoveredNoYesAccidental DentalYesCoveredYes3000Dollars per EpisodeTreatment must begin within 12 months of the injuryNoYesDialysisYesCoveredCovered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysisNoYesAllergy TestingYesCoveredNoYesChemotherapyYesCoveredNoYesRadiationYesCoveredNoYesDiabetes EducationYesCoveredNoYesProsthetic DevicesYesCoveredBenefits include the purchase, fitting, adjustments, repairs and replacementsNoYesInfusion TherapyYesCoveredNoYesTreatment for Temporomandibular Joint DisordersYesCoveredCovered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.NoYesNutritional CounselingYesCoveredNoYesReconstructive SurgeryYesCoveredBenefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.NoYes69512MO0010045Silver Simple Diabetes69512MO001MON001MOS001MOF001ExistingEPOSilverNot ApplicableYesBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010045-00Silver Simple DiabetesSilverStandard Silver Off Exchange PlanYesYesNoYes44%56%$6,500$200$1,900$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,500$6500 per person | $13000 per group50.00%$6,500$6500 per person | $13000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70632826221953970.72%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$0.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010045-01Silver Simple DiabetesSilverStandard Silver On Exchange PlanYesYesNoYes44%56%$6,500$200$1,900$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,500$6500 per person | $13000 per group50.00%$6,500$6500 per person | $13000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70632826221953970.72%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$0.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010045-02AIAN Cost ShareSilverZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1100.00%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010045-03Silver Simple DiabetesSilverLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,000$10000 per person | $20000 per group$10,000$10000 per person | $20000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,500$6500 per person | $13000 per group50.00%$6,500$6500 per person | $13000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70632826221953970.72%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$0.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$65.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010045-04Silver Simple Diabetes CSR 250Silver73% AV Level Silver PlanYesYesNoYes44%56%$5,200$200$2,500$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$8,100$8100 per person | $16200 per group$8,100$8100 per person | $16200 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,200$5200 per person | $10400 per group50.00%$5,200$5200 per person | $10400 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.7374066500086673.87%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$60.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$0.00$20.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$60.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$60.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010045-05Silver Simple Diabetes CSR 200Silver87% AV Level Silver PlanYesYesNoYes44%56%$800$100$2,400$0$0$1,400$0$0$800$50$400$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$3,350$3350 per person | $6700 per group$3,350$3350 per person | $6700 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$800$800 per person | $1600 per group30.00%$800$800 per person | $1600 per group30.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.87453789963938787.53%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$45.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable30.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable30.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$0.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$60.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$35.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010045-06Silver Simple Diabetes CSR 150Silver94% AV Level Silver PlanYesYesNoYes44%56%$0$40$1,500$0$0$500$0$0$0$10$700$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$1,550$1550 per person | $3100 per group$1,550$1550 per person | $3100 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group30.00%$0$0 per person | $0 per group30.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.94320943508883194.35%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Urgent Care Centers or Facilities$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Generic Drugs$0.00$5.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$15.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Allergy Testing$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%

v15.069512MOIndividualNo

Primary Care Visit to Treat an Injury or IllnessYesCoveredCost share applies to both in-person and telemedicine services.NoYesSpecialist VisitYesCoveredGynecologist office visits are covered in full. Cost share applies to both in-person and telemedicine services.NoYesOther Practitioner Office Visit (Nurse, Physician Assistant)YesCoveredNoYesOutpatient Facility Fee (e.g., Ambulatory Surgery Center)YesCoveredNoYesOutpatient Surgery Physician/Surgical ServicesYesCoveredNoYesHospice ServicesYesCoveredNoYesRoutine Dental Services (Adult)Not CoveredInfertility TreatmentNot CoveredLong-Term/Custodial Nursing Home CareNot CoveredPrivate-Duty NursingYesCoveredYes82Visit(s) per Benefit PeriodPrivate Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit.NoYesRoutine Eye Exam (Adult)Not CoveredUrgent Care Centers or FacilitiesYesCoveredVirtual urgent care services provided by Oscar-designated virtual care providers are covered in full.NoYesHome Health Care ServicesYesCoveredYes100Visit(s) per Benefit PeriodTo be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basisNoYesEmergency Room ServicesYesCoveredNoYesEmergency Transportation/AmbulanceYesCoveredNoYesInpatient Hospital Services (e.g., Hospital Stay)YesCoveredNoYesInpatient Physician and Surgical ServicesYesCoveredNoYesBariatric SurgeryNot CoveredCosmetic SurgeryNot CoveredSkilled Nursing FacilityYesCoveredYes150Days per Benefit PeriodLimit includes rehab and outpatient day rehab.NoYesPrenatal and Postnatal CareYesCoveredNoYesDelivery and All Inpatient Services for Maternity CareYesCoveredNoYesMental/Behavioral Health Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesMental/Behavioral Health Inpatient ServicesYesCoveredNoYesSubstance Abuse Disorder Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesSubstance Abuse Disorder Inpatient ServicesYesCoveredNoYesGeneric DrugsYesCoveredCommon prescription generic hormone replacement therapy and SSRIs are covered in full.NoYesPreferred Brand DrugsYesCoveredNoYesNon-Preferred Brand DrugsYesCoveredNoYesSpecialty DrugsYesCoveredNoYesOutpatient Rehabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodTo be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.NoYesHabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodABA for autism only covered through age 18.Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living." 20 Visit(s) per Benefit Period (Outpatient 20 visits per Benefit Period per therapy for physical and occupational therapies)NoYesChiropractic CareYesCoveredChiropractic visits beyond 26 per benefit period require Prior AuthorizationNoYesDurable Medical EquipmentYesCoveredNon-Medically Necessary enhancements to standard equipment and devices.NoYesHearing AidsYesCoveredBenefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.NoYesImaging (CT/PET Scans, MRIs)YesCoveredNoYesPreventive Care/Screening/ImmunizationYesCoveredNoYesRoutine Foot CareYesCoveredCoverage is only available if Medically NecessaryCoverage is available if Medically Necessary.NoYesAcupunctureNot CoveredWeight Loss ProgramsNot CoveredRoutine Eye Exam for ChildrenYesCoveredYes1Exam(s) per Benefit PeriodNoYesEye Glasses for ChildrenYesCoveredYes1Item(s) per YearCovered lenses and frames each available at limit of one per yearNoYesDental Check-Up for ChildrenYesNot CoveredDental Only Plan AvailableRehabilitative Speech TherapyYesCoveredUnlimited visits for speech therapy.NoYesRehabilitative Occupational and Rehabilitative Physical TherapyYesCoveredYes20Visit(s) per Benefit Period20 visit limit each for PT and OT.NoYesWell Baby Visits and CareYesCoveredNoYesLaboratory Outpatient and Professional ServicesYesCoveredDEXA bone density scans, comprehensive metabolic panel, and lab testing for bone health are covered in full.NoYesX-rays and Diagnostic ImagingYesCoveredDEXA bone density scans, comprehensive metabolic panel, and lab testing for bone health are covered in full.NoYesBasic Dental Care - ChildYesNot CoveredDental Only Plan AvailableOrthodontia - ChildYesNot CoveredDental Only Plan AvailableMajor Dental Care - ChildYesNot CoveredDental Only Plan AvailableBasic Dental Care - AdultNot CoveredOrthodontia - AdultNot CoveredMajor Dental Care - AdultNot CoveredAbortion for Which Public Funding is ProhibitedNot CoveredTransplantYesCoveredNoYesAccidental DentalYesCoveredYes3000Dollars per EpisodeTreatment must begin within 12 months of the injuryNoYesDialysisYesCoveredCovered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysisNoYesAllergy TestingYesCoveredNoYesChemotherapyYesCoveredNoYesRadiationYesCoveredNoYesDiabetes EducationYesCoveredNoYesProsthetic DevicesYesCoveredBenefits include the purchase, fitting, adjustments, repairs and replacementsNoYesInfusion TherapyYesCoveredNoYesTreatment for Temporomandibular Joint DisordersYesCoveredCovered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.NoYesNutritional CounselingYesCoveredNoYesReconstructive SurgeryYesCoveredBenefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.NoYes69512MO0010058Silver Simple Women's Health with Menopause Benefits69512MO001MON001MOS001MOF001NewEPOSilverNot ApplicableYesBothNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010058-00Silver Simple Women's Health with Menopause BenefitsSilverStandard Silver Off Exchange PlanYesYesNoYes44%56%$6,000$100$2,100$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,000$6000 per person | $12000 per group50.00%$6,000$6000 per person | $12000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70725612931981171.64%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010058-01Silver Simple Women's Health with Menopause BenefitsSilverStandard Silver On Exchange PlanYesYesNoYes44%56%$6,000$100$2,100$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,000$6000 per person | $12000 per group50.00%$6,000$6000 per person | $12000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70725612931981171.64%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010058-02AIAN Cost ShareSilverZero Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$0$0 per person | $0 per group$0$0 per person | $0 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group0.00%$0$0 per person | $0 per group0.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable1100.00%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Surgery Physician/Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hospice Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Private-Duty Nursing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Urgent Care Centers or Facilities$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Emergency Room Services$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableEmergency Transportation/Ambulance$0.00Not Applicable$0.00Not ApplicableNot ApplicableNot ApplicableInpatient Hospital Services (e.g., Hospital Stay)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Inpatient Physician and Surgical Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Skilled Nursing Facility$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Generic Drugs$0.00$0.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty Drugs$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical Equipment$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Hearing Aids$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Imaging (CT/PET Scans, MRIs)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic Imaging$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Transplant$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Accidental Dental$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Dialysis$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Allergy Testing$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chemotherapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Radiation$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic Devices$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Infusion Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Treatment for Temporomandibular Joint Disorders$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive Surgery$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%69512MO0010058-03Silver Simple Women's Health with Menopause BenefitsSilverLimited Cost Sharing Plan VariationYesYesNoYes44%56%$0$0$0$0$0$0$0$0$0$0$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$10,150$10150 per person | $20300 per group$10,150$10150 per person | $20300 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$6,000$6000 per person | $12000 per group50.00%$6,000$6000 per person | $12000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70725612931981171.64%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$25.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$75.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010058-04Silver Simple Women's Health with Menopause Benefits CSR 250Silver73% AV Level Silver PlanYesYesNoYes44%56%$5,500$100$2,400$0$4,200$200$0$0$2,200$80$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$8,400$8400 per person | $16800 per group$8,400$8400 per person | $16800 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$5,500$5500 per person | $11000 per group50.00%$5,500$5500 per person | $11000 per group50.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.73253020577064173.95%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable50.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$20.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$60.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$40.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010058-05Silver Simple Women's Health with Menopause Benefits CSR 200Silver87% AV Level Silver PlanYesYesNoYes44%56%$870$100$2,400$0$0$1,500$0$0$870$50$400$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$3,350$3350 per person | $6700 per group$3,350$3350 per person | $6700 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$870$870 per person | $1740 per group30.00%$870$870 per person | $1740 per group30.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.87213834929174687.61%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$75.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable30.00% Coinsurance after deductibleEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable30.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$3.00$10.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$60.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$35.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable30.00% Coinsurance after deductibleNot Applicable100.00%69512MO0010058-06Silver Simple Women's Health with Menopause Benefits CSR 150Silver94% AV Level Silver PlanYesYesNoYes44%56%$0$40$1,500$0$0$500$0$0$0$10$700$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$1,550$1550 per person | $3100 per group$1,550$1550 per person | $3100 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$0$0 per person | $0 per group30.00%$0$0 per person | $0 per group30.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.94320943508883194.44%Primary Care Visit to Treat an Injury or Illness$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Urgent Care Centers or Facilities$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Emergency Room ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Emergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable30.00%Inpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Mental/Behavioral Health Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Substance Abuse Disorder Outpatient Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Generic Drugs$0.00$5.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$15.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Outpatient Rehabilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$10.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Allergy Testing$5.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable30.00%Not Applicable100.00%

v15.069512MOIndividualNo

Primary Care Visit to Treat an Injury or IllnessYesCoveredCost share applies to both in-person and telemedicine services.NoYesSpecialist VisitYesCoveredQualified visits for cardiology, pulmonology, and endocrinology are covered in full. Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.NoYesOther Practitioner Office Visit (Nurse, Physician Assistant)YesCoveredNoYesOutpatient Facility Fee (e.g., Ambulatory Surgery Center)YesCoveredNoYesOutpatient Surgery Physician/Surgical ServicesYesCoveredNoYesHospice ServicesYesCoveredNoYesRoutine Dental Services (Adult)Not CoveredInfertility TreatmentNot CoveredLong-Term/Custodial Nursing Home CareNot CoveredPrivate-Duty NursingYesCoveredYes82Visit(s) per Benefit PeriodPrivate Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit.NoYesRoutine Eye Exam (Adult)Not CoveredUrgent Care Centers or FacilitiesYesCoveredVirtual urgent care services provided by Oscar-designated virtual care providers are covered in full.NoYesHome Health Care ServicesYesCoveredYes100Visit(s) per Benefit PeriodTo be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basisNoYesEmergency Room ServicesYesCoveredNoYesEmergency Transportation/AmbulanceYesCoveredNoYesInpatient Hospital Services (e.g., Hospital Stay)YesCoveredNoYesInpatient Physician and Surgical ServicesYesCoveredNoYesBariatric SurgeryNot CoveredCosmetic SurgeryNot CoveredSkilled Nursing FacilityYesCoveredYes150Days per Benefit PeriodLimit includes rehab and outpatient day rehab.NoYesPrenatal and Postnatal CareYesCoveredNoYesDelivery and All Inpatient Services for Maternity CareYesCoveredNoYesMental/Behavioral Health Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesMental/Behavioral Health Inpatient ServicesYesCoveredNoYesSubstance Abuse Disorder Outpatient ServicesYesCoveredThe cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.NoYesSubstance Abuse Disorder Inpatient ServicesYesCoveredNoYesGeneric DrugsYesCoveredCommon prescription generic statins, antiasthmatics, and bronchodilators (inhalers) are covered in full.NoYesPreferred Brand DrugsYesCoveredNoYesNon-Preferred Brand DrugsYesCoveredNoYesSpecialty DrugsYesCoveredNoYesOutpatient Rehabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodCardiac and pulmonary rehab visits are covered in full. To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.NoYesHabilitation ServicesYesCoveredYes20Visit(s) per Benefit PeriodABA for autism only covered through age 18.Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living." 20 Visit(s) per Benefit Period (Outpatient 20 visits per Benefit Period per therapy for physical and occupational therapies)NoYesChiropractic CareYesCoveredChiropractic visits beyond 26 per benefit period require Prior AuthorizationNoYesDurable Medical EquipmentYesCoveredNon-Medically Necessary enhancements to standard equipment and devices.Oxygen is covered in full for members with COPD and other medical conditions that can be treated with long-term supportive oxygen therapy. Prior authorization for medical necessity may apply.NoYesHearing AidsYesCoveredBenefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.NoYesImaging (CT/PET Scans, MRIs)YesCoveredNoYesPreventive Care/Screening/ImmunizationYesCoveredNoYesRoutine Foot CareYesCoveredCoverage is only available if Medically NecessaryCoverage is available if Medically Necessary.NoYesAcupunctureNot CoveredWeight Loss ProgramsNot CoveredRoutine Eye Exam for ChildrenYesCoveredYes1Exam(s) per Benefit PeriodNoYesEye Glasses for ChildrenYesCoveredYes1Item(s) per YearCovered lenses and frames each available at limit of one per yearNoYesDental Check-Up for ChildrenYesNot CoveredDental Only Plan AvailableRehabilitative Speech TherapyYesCoveredUnlimited visits for speech therapy.NoYesRehabilitative Occupational and Rehabilitative Physical TherapyYesCoveredYes20Visit(s) per Benefit Period20 visit limit each for PT and OT.NoYesWell Baby Visits and CareYesCoveredNoYesLaboratory Outpatient and Professional ServicesYesCoveredLabs (HbA1c screening, urinalysis, metabolic panel, lipid panel) are covered in full.NoYesX-rays and Diagnostic ImagingYesCoveredNoYesBasic Dental Care - ChildYesNot CoveredDental Only Plan AvailableOrthodontia - ChildYesNot CoveredDental Only Plan AvailableMajor Dental Care - ChildYesNot CoveredDental Only Plan AvailableBasic Dental Care - AdultNot CoveredOrthodontia - AdultNot CoveredMajor Dental Care - AdultNot CoveredAbortion for Which Public Funding is ProhibitedNot CoveredTransplantYesCoveredNoYesAccidental DentalYesCoveredYes3000Dollars per EpisodeTreatment must begin within 12 months of the injuryNoYesDialysisYesCoveredCovered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysisNoYesAllergy TestingYesCoveredNoYesChemotherapyYesCoveredNoYesRadiationYesCoveredNoYesDiabetes EducationYesCoveredNoYesProsthetic DevicesYesCoveredBenefits include the purchase, fitting, adjustments, repairs and replacementsNoYesInfusion TherapyYesCoveredNoYesTreatment for Temporomandibular Joint DisordersYesCoveredCovered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.NoYesNutritional CounselingYesCoveredNoYesReconstructive SurgeryYesCoveredBenefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.NoYes69512MO0010060Silver 3750 Chronic Care CKM Off Exchange69512MO001MON001MOS001MOF001NewEPOSilverNot ApplicableYesOff the ExchangeNo$0.00 NoAllows Adult and Child-OnlyNoAsthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol11/1/202612/31/2026YesEmergency Services OnlyYesEmergency and Urgent Services OnlyNo69512MO0010060-00Silver 3750 Chronic Care CKM Off ExchangeSilverStandard Silver Off Exchange PlanYesYesNoYes44%56%$3,750$90$2,600$0$0$2,400$0$0$2,200$300$0$0NoMaximum Out of Pocket for Medical and Drug EHB Benefits (Total)$9,500$9500 per person | $19000 per group$9,500$9500 per person | $19000 per groupNot Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicableCombined Medical and Drug EHB Deductible$3,750$3750 per person | $7500 per group40.00%$3,750$3750 per person | $7500 per group40.00%Not Applicableper person not applicable | per group not applicableNot Applicableper person not applicable | per group not applicable0.70249801149505770.71%Primary Care Visit to Treat an Injury or Illness$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialist Visit$95.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Other Practitioner Office Visit (Nurse, Physician Assistant)$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Surgery Physician/Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hospice ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Private-Duty NursingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Urgent Care Centers or Facilities$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Home Health Care ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Emergency Room Services$750.00 Copay after deductibleNot Applicable$750.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableEmergency Transportation/AmbulanceNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable40.00% Coinsurance after deductibleInpatient Hospital Services (e.g., Hospital Stay)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Inpatient Physician and Surgical ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Skilled Nursing FacilityNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Prenatal and Postnatal CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Delivery and All Inpatient Services for Maternity CareNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Mental/Behavioral Health Outpatient Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Mental/Behavioral Health Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Substance Abuse Disorder Outpatient Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Substance Abuse Disorder Inpatient ServicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Generic Drugs$4.00$35.00Not ApplicableNot ApplicableNot Applicable100.00%Preferred Brand Drugs$100.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Non-Preferred Brand Drugs$150.00 Copay after deductibleNot ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Specialty DrugsNot ApplicableNot ApplicableNot Applicable50.00% Coinsurance after deductibleNot Applicable100.00%Outpatient Rehabilitation Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Habilitation Services$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Chiropractic Care$35.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Durable Medical EquipmentNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Hearing AidsNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Imaging (CT/PET Scans, MRIs)Not ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Preventive Care/Screening/ImmunizationNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Routine Foot Care$95.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Routine Eye Exam for Children$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Eye Glasses for ChildrenNot ApplicableNot ApplicableNot Applicable50.00%Not Applicable100.00%Rehabilitative Speech Therapy$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Rehabilitative Occupational and Rehabilitative Physical Therapy$30.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Well Baby Visits and CareNot ApplicableNot ApplicableNot Applicable0.00%Not Applicable100.00%Laboratory Outpatient and Professional Services$25.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%X-rays and Diagnostic ImagingNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%TransplantNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Accidental DentalNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%DialysisNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Allergy Testing$95.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%ChemotherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%RadiationNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Diabetes Education$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Prosthetic DevicesNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Infusion TherapyNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Treatment for Temporomandibular Joint DisordersNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%Nutritional Counseling$0.00Not ApplicableNot ApplicableNot ApplicableNot Applicable100.00%Reconstructive SurgeryNot ApplicableNot ApplicableNot Applicable40.00% Coinsurance after deductibleNot Applicable100.00%