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["State","AK",null,null,null,"AL",null,null,null,"AR",null,null,null,"CA",null,null,null,"CO",null,null,null,"CT",null,null,null,"DE",null,null,null,"FL",null,null,null,"GA",null,null,null,"HI",null,null,null,"IA",null,null,null,"ID",null,null,null,"IL",null,null,null,"IN",null,null,null,"KS",null,null,null,"KY",null,null,null,"LA",null,null,null,"MA",null,null,null,"MD",null,null,null,"ME",null,null,null,"MI",null,null,null,"MN",null,null,null,"MO",null,null,null,"MS",null,null,null,"MT",null,null,null,"NC",null,null,null,"ND",null,null,null,"NE",null,null,null,"NH",null,null,null,"NJ",null,null,null,"NM",null,null,null,"NV",null,null,null,"NY",null,null,null,"OH",null,null,null,"OK",null,null,null,"OR",null,null,null,"PA",null,null,null,"RI",null,null,null,"SC",null,null,null,"SD",null,null,null,"TN",null,null,null,"TX",null,null,null,"UT",null,null,null,"VA",null,null,null,"VT",null,null,null,"WA",null,null,null,"WI",null,null,null,"WV",null,null,null,"WY",null,null,null,"AZ",null,null,null,"DC"]
[null,"EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation","EHB","Limit Quantity","Limit Units","Explanation"]
["Primary Care Visit to Treat an Injury or Illness","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Including doctor visits in the home and online visits.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Specialist Visit","EHB",null,null,null,"EHB",null,null,"One consult per specialist per day.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The Member's Primary Care Physician (PCP) provides a Referral, when one is required, to a Participating Professional Provider when their condition requires a Specialist's Services.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"No referral needed for a specialist.","EHB",null,null,null,"EHB"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)","EHB",null,null,"Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing  a  service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.","EHB",null,null,"Billed as Primary Care Physician Office Visit.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Professional Providers include Physician Assistants. Registered Nurses qualify as Eligible Providers. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Both covered under Nutritional Counseling; nurses and NPs mentioned in multiple other contexts.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Quantitative limits depend on the type of visit. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Practitioner is defined as any person(s) qualified and licensed to practice the healing arts when they are acting within the scope of their license.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes Retail Health Clinics (walk-ins).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document;  benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints.  Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.  Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care.  Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Outpatient Surgery Physician/Surgical Services","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Participants pay a $200 Copayment per covered procedure.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints.  Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or outpatient surgery facility.  Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care.  Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Hospice Services","EHB",6,"Months per Lifetime","Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.","EHB",null,null,null,"EHB",null,null,"If the Member has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, Health Advantage will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by Health Advantage as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits.","EHB",null,null,"Covered for terminally ill patients within the Service Area or inside California but within 15 miles or 30 minutes from the Service Area. ","EHB",null,null,"Life expectancy < 6 months","EHB",null,null,"Covered if the Member has a life expectancy of six months or less and if the care is Pre-Authorized or Pre-Certified.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits must be covered at level that is at least equal to Medicare benefits for both in and out of network providers.","EHB",null,null,null,"EHB",null,null,"Hospice services means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live six months or less).","EHB",null,null,"The Member must have a life expectancy of six (6) months or less.","EHB",null,null,"Members can receive benefits for Hospice Care services by a Home Health Agency covered up to 24 hours during each day of care. Respite Care covered for up to a 48-hour period. ","EHB",null,null,"Coverage includes inpatient and outpatient hospice care.","EHB",30,"Days per Episode","30 days per episode applies to respite and continuous care combined. ","EHB",null,null,null,"EHB",6,"Months per Lifetime","Subject to Care Management. ","EHB",null,null,"A coordinated program of home care and Inpatient Care that provides or coordinates palliative and supportive care to meet the needs of a terminally ill Member and the Member's Immediate Family.","EHB",null,null,"Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.","EHB",null,null,"Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less. Preauthorization is required.","EHB",null,null,"The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",5,"Days per Episode","Limits apply to respite services ('combined maximum benefit of five (5) Inpatient days or five (5) Outpatient visits per Member per ninety (90) days of Home Hospice Care') and to bereavement services ('maximum benefit of five (5) group therapy sessions').","EHB",210,"Days per Year","Also includes 5 visits for family bereavement counseling.","EHB",null,null,"To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.","EHB",null,null,null,"EHB",null,null,"Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.","EHB",null,null,"Respite Care: If the Member were to receive Hospice Care primarily in the home, the Member's primary caregiver may need to be relieved, maximum of seven days every six months. In such a case, the Health Benefit Plan will provide coverage for the Member to receive the same kind of care. ","EHB",null,null,null,"EHB",6,"Months per Episode",null,"EHB",null,null,"Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.","EHB",null,null,"Prior Authorization required for Inpatient Hospice. ","EHB",null,null,"Preauthorization is required.","EHB",6,"Months per 3 Years","Requires Pre-authorization and Medical Case Management.","EHB",null,null,"Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse.  Social services and counseling services from a licensed social worker.  Nutritional support such as intravenous feeding and feeding tubes.  Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member's death. Bereavement services are available to surviving Members of the immediate family for one year after the Member's death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters.","EHB",null,null,null,"EHB",14,"Days per Lifetime",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pre-Certification is required. The Participant must be diagnosed with a terminal illness for which the attending Physician's prognosis for life expectancy is estimated to be six (6) months or less.","EHB",null,null,"The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.","EHB",180,"Days per Benefit Period"]
["Routine Dental Services (Adult)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"Visit(s) per 6 Months"]
["Infertility Treatment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"The following services are covered, including X-ray and laboratory procedures: (a) Services for diagnosis and treatment of involuntary infertility; and (b) artificial insemination, except for donor semen, donor eggs and Services related to their procurement and storage.","EHB",null,null,"If needed carrier may develop explanations pertinent in defining the benefit attributes.",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"In vitro fertilization is the only infertility treatment covered given that certain criteria are met. 1 Treatment per Issuer. ","EHB",null,null,null,null,null,null,null,"EHB",null,null,"Limitations vary based on procedures.",null,null,null,null,"EHB",null,null,"Plan covers Diagnosis and treatment of cause of infertility.  Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary.  Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures. ",null,null,null,null,null,null,null,null,"EHB",null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ","EHB",null,null,"Benefits are limited to: a) Infertility counseling; b) Testing; and c) Artificial Insemination and Intrauterine Insemination. Benefits are available when: (1) The Member and the Member's Spouse have a history of the inability to conceive after one (1) year of unprotected vaginal intercourse; (2) The Member has had a fertility examination that resulted in a physician's recommendation advising artificial insemination or intrauterine insemination; and, (3) The Member's Spouse's sperm is used. Benefits are limited to six (6) attempts per live birth.  ",null,null,null,null,"EHB",null,null,"Underlying causes only.",null,null,null,null,null,null,null,"Covered Services include diagnostic tests to find the cause of infertility and services to treat the underlying medical conditions that cause infertility.",null,null,null,null,"EHB",null,null,"We pay for the diagnosis of infertility & Artificial Insemination (but not listed in the contract).","EHB",3,"Treatment(s) per Lifetime ","Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.",null,null,null,null,null,null,null,null,"EHB",null,null,"Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).","EHB",null,null,"Subject to Horizon BCBSNJ Pre-Approval Horizon BCBSNJ covers charges for procedures and Prescription Drugs to enhance fertility, except where specifically excluded in this Policy. Horizon BCBSNJ covers charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception.","EHB",null,null,"Diagnosis and medically indicated treatments for physical conditions causing infertility","EHB",6,"Procedure(s) per Lifetime","Covered services include office visit evaluation and limited: 1. Laboratory studies; 2. Diagnostic procedures; and 3. Artificial insemination services, up to six (6) cycles per Member per lifetime.","EHB",null,null,"Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. Members must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate for these services.","EHB",null,null,"Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.",null,null,null,null,null,null,null,null,"EHB",null,null,"Artificial Insemination is covered: Facility services provided by a Participating Facility Provider and services performed by a Referred Specialist for the promotion of fertilization of a female recipient's own ova (eggs).","EHB",3,"Treatment(s) per Year","In order to be covered, must be married, unable to conceive and healthy. Three (3) infertility treatment cycles will be covered per plan year with a total of eight (8) infertility treatment cycles covered in a member's lifetime.",null,null,null,null,null,null,null,null,null,null,null,"Services or supplies for the evaluation of infertility.",null,null,null,"State law mandates an offer of coverage for in vitro in the group market. Diagnosis covered but treatment not covered unless a rider is purchased to cover In-vitro ONLY. NOT artificial Insemination.  ",null,null,null,null,null,null,null,"Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).",null,null,null,"Evaluations to determine if and why a covered member is infertile are covered.",null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,"Benefits will not be provided for artificial insemination, in vitro ('test tube') fertilization, or other artificial methods of conception.",null,null,null,"Diagnostic services rendered for infertility evaluation are covered. Any medical treatment and/or prescription related to infertility once diagnosed are excluded by the Plan."]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"For hospital inpatient care, private duty nursing covered when a Plan Physician determines it is Medically Necessary.",null,null,null,null,"EHB",240,"Hours per Year","Private duty nursing care is covered when you are an inpatient in an acute hospital.",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.",null,null,null,null,"EHB",null,null,null,"EHB",82,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",250,"Visit(s) per Year","One visit equals eight hours of skilled care services.","EHB",5000,"Dollars per Benefit Period",null,null,null,null,null,null,null,null,"Private duty nursing is excluded, unless authorized by CareFirst BlueChoice.",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",82,"Visit(s) per Benefit Period","Private duty nursing services are a Covered Service only when given as part of the 'Home Care Services' benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined. ",null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Horizon BCBSNJ only covers charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section.",null,null,null,null,"EHB",null,null,"Covered when provided by 'a Hospital, Ambulatory Surgical Facility, Skilled Nursing Facility or Hospice Care Facility', subject to the benefit limitation for such facility services. ",null,null,null,null,"EHB",90,"Visit(s) per Benefit Period","Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.","EHB",85,"Visit(s) per Benefit Period","Pre-authorization required.",null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Plan refers to home skilled nursing as private duty nursing.  Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting. ",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",16,"Hours per Benefit Period",null,"EHB",null,null,null,null,null,null,null,null,null,null,null,"EHB",35,"Visit(s) per Benefit Period",null,"EHB",null,null,"Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant's Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities.","EHB",null,null,"Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan."]
["Routine Eye Exam (Adult)",null,null,null,null,null,null,null,null,null,1,"Exam(s) per 2 Years",null,null,null,null,null,null,null,null,"Wellness and refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses are covered. Also covered are professional exams and the fitting of Medically Necessary contact lenses when a Plan Physician or Plan Optometrist prescribes them for a specific medical condition. Professional Services for exams and fitting of contact lenses that are not Medically Necessary are provided at an additional Charge when obtained at Health Plan Medical Offices.",null,null,null,null,null,1,"Visit(s) per 2 Years",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"Exam(s) per 2 Years",null,null,null,null,null,null,1,"Exam(s) per Year","One eye exam every 12 months from last date of service.  Adult frames and lenses or contact lenses covered once every 24 months.",null,1,"Exam(s) per Year","Included as part of annual physical exam.",null,300,"Dollars per Year","$300 limit per calendar year on non-network tier.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Coverage is provided for vision exams only when required to diagnose an Illness or Injury. ",null,null,null,null,null,null,null,"Routine eye exam and refraction are not covered, as well as services for vision training and orthoptics, eyeglasses and eyewear (except for eyeglasses or contact lenses for cataract surgery or injury covered under durable medical benefits).",null,null,null,null,null,null,null,null,null,1,"Visit(s) per Year",null,null,1,"Exam(s) per Year",null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"Exam(s) per Year",null,null,null,null,null,null,1,"Exam(s) per Benefit Period",null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"Exam(s) per Year"]
["Urgent Care Centers or Facilities","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Emergency Medical Services-Outpatient.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share is driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Home Health Care Services","EHB",130,"Visit(s) per Year","130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work.","EHB",null,null,null,"EHB",50,"Visit(s) per Year","Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.).","EHB",100,"Visit(s) per Year","Covered if you are confined to a home within the Service Area, your condition requires the services of a healthcare professional, and your services are approved by a Plan Physician.","EHB",28,"Hours per Week","Skilled nursing care, home health aide services and medical social Services are covered: a. only on a Part-Time Care or Intermittent Care basis; and b. only within our Service Area; and c. only if you are confined to your home; and d. only if a Plan Physician determines that it is feasible to maintain effective supervision and control of your care in your home. Services must be clinically indicated; may not exceed 28 hours per week combined over any number of days per week; and must be for less than eight (8) hours per day. Health Plan may approve additional time up to 35 hours per week but less than eight (8) hours per day on a case-by-case basis.","EHB",100,"Visit(s) per Year",null,"EHB",100,"Visit(s) per Benefit Period","There's a limit of one visit per day per specialty. (A nurse and home health aide count as one specialty for this benefit.)","EHB",20,"Days per Benefit Period",null,"EHB",120,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",100,"Visit(s) per Benefit Period","Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.","EHB",null,null,"Includes educational visits with a limit of three per year on educational visits. ","EHB",100,"Visit(s) per Year","One visit equals at least four hours of skilled care services.","EHB",null,null,"Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization.","EHB",null,null,null,"EHB",null,null,"Unlimited when provided in lieu of hospitalization or confinement in a skilled nursing facility.  Additional benefits for a member who receives less than forty eight hours of impatient hospitalization following the surgical removal of a testicle or Mastectomy, or who undergoes the surgical removal of a testicle or Mastectomy on an outpatient basis, benefits will be provided for Testicle and Mastectomy,  Visits: One home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility and additional home visit if prescribed by the Member's attending physician. Additional visits for postpartum care as follows:  If the mother and newborn child stay in the hospital less than 48 hours for vaginal delivery or 96 hours for cesarean section, one home visit within 24 hours after hospital discharge and an additional home visit if prescribed by attending provider.  If the mother and child remain in the hospital for at least 48 hours after vaginal delivery or 96 hours after cesarean section, one home care visit, if prescribed by attending physician.","EHB",null,null,null,"EHB",null,null,null,"EHB",120,"Visit(s) per Year","Must be Medically Necessary, provided as rehabilitative care, terminal care or maternity care, and ordered by a physician in a written home care plan.","EHB",100,"Visit(s) per Benefit Period","To 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 basis.                                              ","EHB",null,null,"May be available through the Care Management Program when provided by a network provider and prior authorization is received. ","EHB",180,"Visit(s) per Benefit Period","Includes Nursing services, Home Health Aide services, Hospice services, Physical Therapy, Occupational Therapy, Speech Therapy, Medical social worker, Medical supplies and equipment suitable for use in the home, Medically Necessary personal hygiene, grooming and dietary assistance.","EHB",null,null,null,"EHB",40,"Visit(s) per Benefit Period","Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services.  A visit is considered up to 4 continuous hours.","EHB",60,"Days per Year",null,"EHB",null,null,null,"EHB",60,"Visit(s) per Year",null,"EHB",100,"Days per Year",null,"EHB",null,null,"Unlimited benefit except for One (1) medical social service consultation per course of treatment; One (1) nutrition consultation by a certified registered dietitian; and health aide services are furnished only when receiving nursing services or therapy. ","EHB",40,"Visit(s) per Year","Each visit of up to four hours by a home health aide is one visit.","EHB",100,"Visit(s) per Benefit Period","When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services.  The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.","EHB",30,"Visit(s) per Benefit Period",null,"EHB",null,null,null,"EHB",60,"Visit(s) per Benefit Period",null,"EHB",null,null,null,"EHB",60,"Visit(s) per Benefit Period",null,"EHB",null,null,null,"EHB",60,"Visit(s) per Year",null,"EHB",60,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period",null,"EHB",100,"Visit(s) per Benefit Period","Visit limit does not apply to home infusion therapy or home dialysis.  The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home.  Benefit includes intermittent skilled nursing services by an R.N. or L.P.N.; Medical/social services; Diagnostic services; Nutritional guidance; Training of the patient and/or family/caregiver; Home health aide services; Therapy Services; Medical supplies; Durable medical equipment.","EHB",null,null,null,"EHB",130,"Visit(s) per Year",null,"EHB",60,"Visit(s) per Year","Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. ","EHB",100,"Visit(s) per Benefit Period","The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.","EHB",null,null,"Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant's hospitalization was required. ","EHB",42,"Visit(s) per Year","1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary by the Medical Management Organization.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.","EHB",90,"Visit(s) per Episode","A new episode of care begins if the member does not receive Home Health Care for the same or a different condition for 60 consecutive days. Prior authorization is required."]
["Emergency Room Services","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits are available in a Hospital Emergency Room for services and supplies to treat the onset of symptoms for a medical emergency.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Emergency Transportation/Ambulance","EHB",null,null,"Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Ambulances are covered for emergencies or non-emergencies when approved by a Plan Physician. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Air ambulance is covered only when no other means of travel is appropriate.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Emergency transportation/ambulance within 500 mile radius.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility. Benefits for air transportation are available only when ground transportation is not Medically Appropriate and Necessary as determined by BCBSND. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or  from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities.  Includes ground, water, fixed wing and rotary air transportation.  Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Inpatient Hospital Services (e.g., Hospital Stay)","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).  Limit is combined both In and Out of Network.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",365,"Days per Episode",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.","EHB",null,null,null,"EHB",null,null,"Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services.  Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.  ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.","EHB",null,null,null,"EHB",null,null,"Prior authorization is required except for emergency admissions and all maternity admissions. Hospitalization solely for rehabilitation limited to ninety (90) days per Benefit Period. Limitations for other reasons are variable and outlined in respective section."]
["Inpatient Physician and Surgical Services","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",365,"Days per Episode",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The Health Benefit Plan will provide coverage for surgical services provided: By a Participating Professional Provider, and/or a Participating Facility Provider; For the treatment of disease or injury.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care.  Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.","EHB",null,null,null,"EHB"]
["Bariatric Surgery",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,"You must meet health plan's criteria to be eligible for coverage.",null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Precertification is required.","EHB",null,null,"Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.",null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Recipients must be diagnosed as morbidly obese for a minimum of five consecutive years. Benefits are limited to surgery for an intestinal bypass, gastric bypass, or gastroplasty.","EHB",1,"Procedure(s) per Lifetime",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"For surgical treatment of morbid obesity.","EHB",1,"Procedure(s) per Lifetime","Surgery for morbid obesity after Prior Approval is received from BCBSND. Covered Services must be received from a surgical facility approved by BCBSND. Benefits are subject to a Lifetime Maximum of 1 operative procedure for morbid obesity per Member. Guidelines and criteria are available upon request. No benefits are available for the repair or modification of any or all types of surgical morbid obesity procedures, except a Lifetime Maximum of 1 revision will be allowed per Member due to technical staple line failure. Benefits for all proposed surgical procedures for the treatment of complications resulting from any or all types of surgical morbid obesity procedures are available only when Prior Approval is received from BCBSND.",null,null,null,null,"EHB",null,null,"Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. ","EHB",null,null,"The policy provides coverage for medically necessary and appropriate surgery.  Bariatric surgery is surgery and to the extent it is medically necessary and appropriate for the patient, is covered.  ","EHB",null,null,"Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions.","EHB",1,"Procedure(s) per Lifetime","Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the following circumstances: BMI of greater than 40kg/m2; or BMI greater than 35kg/m2 with significant comorbidities; and provide documented evidence that dietary attempts at weight control are ineffective; and at least 18 years old.  ","EHB",null,null,null,null,null,null,"Directly related means that the treatment or surgery occurred as a direct result of, and would not have taken place in the absence of, the bariatric surgery. This exclusion does not apply to conditions including but not limited to: myocardial infarction; pulmonary embolism, thrombophlebitis, and exacerbation of co-morbid conditions during the procedure or in the immediate post-operative time frame. All medically necessary Basic Health Care services must be covered by an HMO plan.  Complications from a non-covered procedure that require the need for any medically necessary Basic Health Care Service must be covered same as any other services.",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"To treat functional impairment when medically necessary.",null,null,null,null,"EHB",null,null,"Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.",null,null,null,null,null,null,null,null,null,null,null,"Surgery performed in conjunction with obesity Surgery requires pre-notification and pre-authorization.",null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Surgery determined to be Medically Necessary is covered.","EHB",1,"Procedure(s) per Lifetime","Pre-certification is required.  Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.","EHB",null,null,"1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth."]
["Cosmetic Surgery",null,null,null,"Exceptions to no coverage for cosmetic surgery: Repair of a defect that's the direct result of an accidental injury, providing such repair is started within 12 months of the date of the accident. Repair of a dependent child's congenital anomaly. Reconstructive breast surgery in connection with a mastectomy as provided under the Mastectomy and Breast Reconstruction Services benefit. Correction of functional disorders (not including removal of excess skin and/or fat related to weight loss surgery or the use of obesity drugs), upon our review and approval.",null,null,null,null,null,null,null,"Cosmetic Services excluded, but exclusion does not include 'the following services in connection with a mastectomy resulting from cancer: (a) reconstruction of the breast on which the cancer-related surgery has been performed, and (b) surgery to reconstruct the other breast to produce a symmetrical appearance. The following procedures performed on a child age 12 years and under are not considered Cosmetic Services: correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma on the face, correction of a non-dental congenital abnormality.' ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Excludes 'Surgery or related services for Cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, congenital, or developmental anomalies.'",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Only medically necessary cosmetic surgery is covered to treat accidents and genetic defects.  ",null,null,null,null,null,null,null," Cosmetic surgery will not qualify as reconstructive surgery when performed for the treatment of a psychological or psychiatric condition.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Directly related means that the treatment or surgery occurred as a direct result of, and would not have taken place in the absence of, the cosmetic surgery. This exclusion does not apply to conditions including but not limited to: myocardial infarction; pulmonary embolism, thrombophlebitis, and exacerbation of co-morbid conditions during the procedure or in the immediate post-operative time frame. All medically necessary Basic Health Care services must be covered by an HMO plan.  Complications from a non-covered procedure that require the need for any medically necessary Basic Health Care Service must be covered same as any other services.",null,null,null,null,"EHB",null,null,"Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery.",null,null,null,"The plan exclusion for cosmetic surgery does not include those services performed in order to restore bodily function or correct deformity resulting from:  A disease; Recent trauma; or Previous therapeutic process.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Covered only for the correction of congenital deformities in children, conditions resulting from accidental injuries, and reconstructive surgery following cancer surgery including prosthesis in the event of a mastectomy.",null,null,null,"Surgery that may be partially or wholly cosmetic requires written pre-authorization.",null,null,null,null,null,null,null,null,null,null,null,"Covers cosmetic surgery for congenital anomalies.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Cosmetic surgery or procedures excluded, other than to treat congenital defects and birth abnormalities."]
["Skilled Nursing Facility","EHB",60,"Days per Year",null,null,null,null,null,"EHB",60,"Days per Year","1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function.","EHB",100,"Days per Benefit Period",null,"EHB",100,"Days per Year","The following services are covered: a. Room and board. b. Nursing care. c. Medical social services. d. Medical and biological supplies. e. Blood, blood products and their administration.","EHB",90,"Days per Year","If needed carrier may develop explanations pertinent in defining the benefit attributes.","EHB",120,"Days per Admission","Coverage is limited to 120 days per confinement. A confinement includes all admissions not separated by 180 days.  ","EHB",60,"Days per Benefit Period",null,"EHB",60,"Days per Year",null,"EHB",120,"Days per Year",null,"EHB",null,null,null,"EHB",30,"Days per Benefit Period",null,"EHB",null,null,null,"EHB",90,"Days per Benefit Period","Limit is combined both In and Out of Network.",null,null,null,null,"EHB",90,"Days per Year","90 days per year in a Skilled Nursing Facility. 60 days per year in an Inpatient Rehabilitation Facility.","EHB",null,null,null,"EHB",100,"Days per Year","Benefit limit per member.","EHB",100,"Days per Benefit Period",null,"EHB",150,"Days per Year",null,"EHB",45,"Days per Year",null,"EHB",120,"Days per Episode",null,"EHB",150,"Days per Benefit Period","Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab. ",null,null,null,null,"EHB",60,"Days per Benefit Period","Also referred to as 'convalescent home.'","EHB",60,"Days per Benefit Period",null,"EHB",30,"Days per Benefit Period","Preauthorization is required. ","EHB",60,"Days per Year",null,"EHB",100,"Days per Benefit Period","When you require Inpatient skilled nursing and related services for convalescent and rehabilitative care, Covered Services are available if the Facility is licensed or certified under state law as a Skilled Nursing Facility.","EHB",null,null,"Referred to as Extended Care Center.","EHB",60,"Days per Year",null,"EHB",100,"Days per Year",null,"EHB",200,"Days per Year",null,"EHB",90,"Days per Benefit Period","Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.","EHB",30,"Days per Benefit Period",null,"EHB",60,"Days per Year",null,"EHB",120,"Days per Benefit Period","120 Inpatient days for the Benefit Period Maximum.","EHB",null,null,null,"EHB",60,"Days per Benefit Period",null,"EHB",90,"Days per Benefit Period",null,"EHB",60,"Days per Year","Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined. ","EHB",25,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period","Requires Pre-authorization and Medical Case Management.","EHB",100,"Days per Stay","Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary.  ","EHB",null,null,null,"EHB",60,"Days per Year","Coverage is limited to 60-inpatient days/year.","EHB",30,"Days per Stay",null,"EHB",null,null,null,"EHB",null,null,"Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility.","EHB",90,"Days per Year",null,"EHB",60,"Days per Benefit Period","Member must require care on a daily basis, care must not be custodial, and care must only be provided on an inpatient basis. Prior authorization is required."]
["Prenatal and Postnatal Care","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Newborn child of participant covered for the first 61 days following birth; after, must be signed up.  Newborn grandchild covered for 61 days if mother is enrolled daughter of participant; no mention of eligibility if the father is the son of the participant.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Also covers surrogate mother if there is a petition to adopt within 90 days of birth.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient's discretion, in a medical setting.  This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pre-notification: The Health Benefit Plan should be notified of the need for maternity care within one month of the first prenatal visit to the Physician or midwife.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Delivery and All Inpatient Services for Maternity Care","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Also covers surrogate mother if there is a petition to adopt within 90 days of birth.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.  ","EHB",null,null,null,"EHB",null,null,"Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother's normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship. ","EHB"]
["Mental/Behavioral Health Outpatient Services","EHB",null,null,null,"EHB",20,"Days per Year","If mental Health services provided through Expanded Psychiatric Service (EPS) provider, 30 days of outpatient care covered, if not through EPS 20 days.","EHB",null,null,"Coverage of office visits and other outpatient treatment sessions, beyond the eighth session in a calendar year, except for medication management treatment sessions, is subject to Prior Approval from the Company. Coverage for many Health Interventions for the treatment of Mental Illness and Substance Abuse are subject to Prior Approval from the Company.","EHB",null,null,null,"EHB",null,null,"Covered are: diagnostic evaluation; individual therapy; psychiatric treatment; and psychiatrically oriented child and teenage guidance counseling. Visits for the purpose of monitoring drug therapy are covered. Psychological testing as part of diagnostic evaluation is covered. Mental Health Wellness Exam ","EHB",null,null,null,"EHB",null,null,"Psychological tests (limit of 8 hours of tests per year).","EHB",20,"Visit(s) per Benefit Period",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).","EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share is driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",52,"Visit(s) per Year",null,"EHB",null,null,"The care and treatment of mental illness provided by a hospital; a physician or prescribed by a physician; a mental health treatment center; a chemical dependency treatment center; a psychologist, a licensed social worker; a licensed professional addiction counselor, a licensed clinical professional counselor or a licensed psychiatrist. Outpatient benefits must be provided to diagnose and treat recognized mental illness and treatment must be reasonably expected to improve and restore the level of functioning that has been affected by the mental illness.","EHB",null,null,null,"EHB",null,null,"For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"All inpatient and non-routine Outpatient non-emergency Mental Health, Severe Mental Illness or Substance Abuse require Prior Authorization.","EHB",null,null,null,"EHB",null,null,"Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.","EHB",null,null,"Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",25,"Visit(s) per Benefit Period","25 Outpatient/office visits for Mental Health Services/Substance Abuse care (combined office, outpatient Facility and Physician).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Preauthorization is required.","EHB",null,null,null,"EHB",null,null,"Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), mental health clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Mental/Behavioral Health Inpatient Services","EHB",null,null,null,"EHB",30,"Days per Year","30 day limit when not coordinated by EPS provider.","EHB",null,null,"Coverage for many Health Interventions for the treatment of Mental Illness and Substance Abuse are subject to Prior Approval from the Company.","EHB",null,null,null,"EHB",null,null,"Covered are psychiatric hospitalization in a facility designated by Health Plan. Hospital Services for psychiatric conditions include all Services of Plan Physicians and mental health professionals and the following Services and supplies as prescribed by a Plan Physician while you are a registered bed patient: room and board; psychiatric nursing care; group therapy; electroconvulsive therapy; occupational therapy; drug therapy; and medical supplies.","EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Days per Benefit Period",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",365,"Days per Episode",null,"EHB",null,null,null,"EHB",30,"Days per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"All inpatient non-emergency Mental Health, Severe Mental Illness or Substance Abuse require Prior Authorization. ","EHB",null,null,null,"EHB",null,null,"Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.","EHB",null,null,"Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",7,"Days per Benefit Period",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Preauthorization is required.","EHB",null,null,"Requires Pre-authorization. ","EHB",null,null,"Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient's diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Substance Abuse Disorder Outpatient Services","EHB",null,null,null,"EHB",20,"Days per Year","If mental Health services provided through Expanded Psychiatric Service (EPS) provider, 30 days of outpatient care covered, if not through EPS 20 days.","EHB",null,null,"Coverage of office visits and other outpatient treatment sessions, beyond the eighth session in a calendar year, except for medication management treatment sessions, is subject to Prior Approval from the Company. Coverage for many Health Interventions for the treatment of Mental Illness and Substance Abuse are subject to Prior Approval from the Company.","EHB",null,null,null,"EHB",null,null,"Outpatient rehabilitative services for the treatment of alcohol and drug dependency are covered when referred by a Plan Physician.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).","EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share is driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",20,"Days per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Outpatient benefits include diagnostic, evaluation and treatment services provided by a Physician, Licensed Clinical Psychologist or Licensed Addiction Counselor, including for gambling addiction.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"All non-routine Outpatient Substance Abuse require Prior Authorization.","EHB",null,null,"Also includes 20 visits per year for family counseling. ","EHB",null,null,"Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.","EHB",null,null,"Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",25,"Visit(s) per Benefit Period","25 Outpatient/office visits for Mental Health Services/Substance Abuse care (combined office, outpatient Facility and Physician).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Certain services require preauthorization.","EHB",null,null,null,"EHB",null,null,"Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), mental health clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.","EHB",null,null,"Health plans may limit coverage of substance use disorder treatment services to Medically Necessary Care in the least restrictive setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Substance Abuse Disorder Inpatient Services","EHB",null,null,null,"EHB",30,"Days per Year",null,"EHB",null,null,"Coverage for many Health Interventions for the treatment of Mental Illness and Substance Abuse are subject to Prior Approval from the Company.","EHB",null,null,"$400 Copayment per day in Plan Hospital only for medical management of withdrawal symptoms.","EHB",null,null,"Services are covered for the medical management of withdrawal symptoms. Medical services for alcohol and drug detoxification are covered in the same way as for other medical conditions. Detoxification is the process of removing toxic substances from the body.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",365,"Days per Episode",null,"EHB",null,null,null,"EHB",7,"Days per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits are available for the inpatient treatment of substance abuse, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Abuse Facility. Benefits available for residential treatment for members under age 21. Benefits available for partial hospitalization. Preauthorization is required. For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"All inpatient Substance Abuse require Prior Authorization. ","EHB",null,null,null,"EHB",null,null,"Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.","EHB",null,null,"Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Residential/Rehabilitation and detox have unlimited days per plan year.","EHB",7,"Days per Benefit Period",null,"EHB",90,"Days per Lifetime","Quantity Limit: 30 days/six-month period for inpatient treatment and 90 days/lifetime for inpatient treatment for alcoholism treatment. Quantity Limit for all other substance abuse inpatient treatment: 30 days/benefit year for inpatient treatment.","EHB",null,null,null,"EHB",null,null,"Preauthorization is required.","EHB",null,null,"Requires Pre-authorization. ","EHB",null,null,"Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient's diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.","EHB",null,null,"Health plans may limit coverage of substance use disorder treatment services to Medically Necessary Care in the least restrictive setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Generic Drugs","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Treatment(s) per Month",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Item(s) per Month",null,"EHB",null,null,"Covers prescription legend drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration).  Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain.","EHB",null,null,null,"EHB",30,"Days per Month","Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Limited to a 34-day supply of Prescription Drugs."]
["Preferred Brand Drugs","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Treatment(s) per Month",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Item(s) per Month",null,"EHB",null,null,"Covers prescription legend drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration).  Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain.","EHB",null,null,null,"EHB",30,"Days per Month","Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Limited to a 34-day supply of Prescription Drugs."]
["Non-Preferred Brand Drugs","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Item(s) per Month",null,"EHB",null,null,"Covers prescription legend drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration).  Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain.","EHB",null,null,null,"EHB",30,"Days per Month","Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.","EHB",null,null,null,"EHB",null,null,"Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan.  We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription.  However, your Physician or Professional Other Provider will always make the final decision on your medication.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Limited to a 34-day supply of Prescription Drugs."]
["Specialty Drugs","EHB",null,null,null,"EHB",null,null,"A drug included in the Specialty Drug List may also be considered a generic, preferred brand name, or other brand name drug. If a drug falls into multiple categories, the drug will be considered a specialty drug, and not a generic drug or other type of drug, as long as it remains on the Specialty Drug List.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Specialty drugs may be limited to a thirty (30) day supply.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Treatment(s) per Month",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Specialty Drugs are subject to a dispensing limit of a 30-day supply. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The Health Benefit Plan will only provide benefits for covered Specialty Drugs, except Insulin, through the pharmacy benefits manager's (PBM's) Specialty Pharmacy Program for the appropriate cost sharing indicated in the Schedule of Benefits for a Participating Pharmacy. Benefits are available for up to a 30 day supply. Preapproval is required for those Specialty Drugs noted in the Preapproval list which is available on-line or by calling Customer Service at the phone number shown on the Member's ID card.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Item(s) per Month",null,"EHB",null,null,"Covers prescription legend drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration).  Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain.","EHB",null,null,null,"EHB",30,"Days per Month","First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must be pre-approved.","EHB",null,null,null,"EHB",null,null,"Limited to a 34-day supply of Prescription Drugs."]
["Outpatient Rehabilitation Services","EHB",45,"Visit(s) per Year","A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers.","EHB",null,null,"While outpatient rehab is not mentioned, occupational, physical and speech therapy with combined limit (30 visits per year).","EHB",30,"Visit(s) per Year","Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; appears to also combine hab and rehab.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Limit is per therapy.","EHB",40,"Visit(s) per Year","Limit is combined for PT, ST and OT.","EHB",30,"Visit(s) per Benefit Period","Combined visits for rehab and hab:  30 visits combined for OT and PT; 30 visits for ST. ","EHB",35,"Visit(s) per Benefit Period","Combined limit for all outpatient therapy plus chiropractic.  ","EHB",40,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",20,"Visit(s) per Benefit Period",null,"EHB",null,null,"Maintenance therapies not covered.","EHB",60,"Visit(s) per Benefit Period","Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).  Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.","EHB",90,"Days per Benefit Period","These therapies include but are not limited to PT, OT, and ST. Further, '(Rehab) services are covered only if they are expected to result in significant improvement in the Insured's condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred'. 'Speech Therapy', limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.","EHB",25,"Visit(s) per Year","Includes yearly limits: 25 PT visits, 25 OT visits, 25 ST visits.","EHB",null,null,null,"EHB",60,"Visit(s) per Year","60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","EHB",30,"Visit(s) per Benefit Period","30 visits each per injury or illness per benefit period for each of OT, PT, and ST.","EHB",20,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","PT/OT/Chiro - combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year.","EHB",null,null,"20 visit limit for non-network tier. ","EHB",20,"Visit(s) per Benefit Period","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. ","EHB",36,"Visit(s) per Year","Benefits available for outpatient cardiac rehabilitation.","EHB",null,null,"Rehabilitation Therapy: A specialized, intense and comprehensive program of therapies and treatment services (including but not limited to Physical Therapy, Occupational Therapy and Speech Therapy) provided by a Multidisciplinary Team for treatment of an Injury or physical deficit. Also an Outpatient Therapies benefit.","EHB",30,"Visit(s) per Benefit Period","Combined 30 visit limit for occupational and physical therapies and chiropractic services.","EHB",30,"Visit(s) per Benefit Period","Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness.  30-visit limit is for each of PT, OT, and ST, rehab and hab combined.  Benefits are not available for Maintenance Care.","EHB",45,"Treatment(s) per Year","Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).","EHB",20,"Visit(s) per Benefit Period","20 visits each per PT, OT, ST. ","EHB",30,"Visit(s) per Year","Coverage for Physical Therapy and Occupational Therapy, combined, is limited to 30 visits per calendar year; coverage of cognitive rehabilitation therapy and speech therapy, combined, is limited to 30 visits per calendar year.","EHB",null,null,null,"EHB",120,"Visit(s) per Year","All Inpatient and Outpatient Short Term Rehabilitation and Habilitative Services are subject to a combined maximum benefit of one hundred twenty (120) days/visits per Member per Calendar Year.","EHB",60,"Visit(s) per Year","60 visits per condition per year combined.  Physical and speech therapy are only covered following a hospital stay or surgery. ","EHB",60,"Visit(s) per Benefit Period","Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits.  Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis.  Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. ","EHB",30,"Days per Benefit Period",null,"EHB",30,"Visit(s) per Year",null,"EHB",36,"Visit(s) per Benefit Period","Includes Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, Respiratory Therapy.","EHB",null,null,"Short-term therapies are services that result in measurable and meaningful functional improvements within sixty (60) days. Must be provided as part of a defined treatment plan for an acute illness, injury, or an acute exacerbation of a chronic illness with significant potential for functional recovery.","EHB",null,null,null,"EHB",null,null,null,"EHB",20,"Visit(s) per Year","Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.","EHB",35,"Visit(s) per Year","Limited to combined 35 visits per year, including Chiropractic. ","EHB",20,"Visit(s) per Benefit Period","Pre-authorization required only for home visits. Rehabilitation therapy will be defined as, The treatment of disease, injury, developmental delay or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal oriented and where the Member has the potential for functional improvement and ability to progress.","EHB",null,null,"Benefits are based on the setting in which covered services are received.  See individual therapy limits.","EHB",30,"Visit(s) per Year",null,"EHB",25,"Visit(s) per Year",null,"EHB",null,null,"Rehabilitative services must be short term.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Outpatient Rehabilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.","EHB",60,"Visit(s) per Year","Short-term rehabilitative therapy includes services in an outpatient facility or physician's office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy.  Visit limit is for all therapy types combined.","EHB"]
["Habilitation Services","EHB",45,"Visit(s) per Year","Habilitative services is only covered in the context of autism spectrum disorders services, including ABA, counseling and treatment programs necessary to develop, maintain, or restore the functioning of an individual.","EHB",null,null,"While habilitation services is not mentioned, for children aged 0-9 with autism only: 35 visits for speech therapy and 35 visits for occupational therapy per child each calendar year. ","EHB",30,"Visit(s) per Year","Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; appears to also combine hab and rehab.","EHB",null,null,"Covered even if 100% functionality is not possible.","EHB",60,"Visit(s) per Year","Visit limit per therapy.","EHB",40,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period","Combined limits for rehab and hab apply to Speech (30 visits), Occupational and Physical therapy (30 visits for OT and PT combined).  Applied Behavior analysis for autism spectrum disorder is also covered, with a combined limit of $36,000 per benefit period for members under 21.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",40,"Visit(s) per Year","Habilitative services apply toward the 'Physical medicine and rehabilitative services' maximum number of visits specified in the 'Schedule of Benefits'.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",null,null,"Treatment for Autism with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavior Analysis for the treatment of Autism is not covered.","EHB",null,null,null,"EHB",null,null,"Treatment must be medically necessary and therapeutic and not investigational.","EHB",60,"Visit(s) per Benefit Period","Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services.  Limits are combined both In and Out of Network.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",25,"Visit(s) per Year","Habilitative services means occupational therapy, physical therapy and speech therapy prescribed by the Covered Person's treating Physician pursuant to a treatment plan to develop a function not currently present as a result of a congenital, genetic, or early acquired disorder.  Includes yearly visits limits that are the same as the outpatient rehabilitation services limits: 25 PT visits; 25 OT visits; and 25 ST visits.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",null,null,null,"EHB",30,"Visit(s) per Benefit Period","Limits only apply for adults, and are the same as rehab limits (30 visits per injury or illness per benefit period for each of PT, OT, ST). Habilitative defined as 'the process of educating or training persons with a disadvantage or disability caused by a medical condition or injury to improve their ability to function in society, where such ability did not exist, or was severely limited, prior to the Habilitative education or training.' For Members from birth to age nineteen (19) for treatment of Congenital or Genetic Birth Defects, Benefits for Habilitative services will be provided for services including services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, audiological, and speech therapy, physical therapy, and occupational therapy. ","EHB",null,null,null,"EHB",30,"Visit(s) per Year","Yearly limits: PT and OT: 30 visits, Speech: 30 visits.","EHB",null,null,"20 visit limit for non-network tier.  ","EHB",20,"Visit(s) per Benefit Period","Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.' ","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",null,null,"Coverage will be provided for Habilitative Care services when the Member requires help to keep, learn or improve skills and functioning for daily living. These services include, but are not limited to: physical and occupational therapy; speech-language pathology; and other services for people with disabilities. These services may be provided in a variety of Inpatient and/or Outpatient settings as prescribed by a Physician.","EHB",30,"Visit(s) per Benefit Period ","Combined 30 visit limit for occupational and physical therapies and chiropractic services.","EHB",30,"Visit(s) per Benefit Period","Habilitative Physical Therapy, Occupational Therapy or Speech Therapy is care provided for conditions which have limited the normal age appropriate motor, sensory or communication development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward a Member's maximum potential.Functional skills are defined as essential activities of daily life common to all Members such as dressing, feeding, swallowing, mobility, transfers, fine motor skills, age appropriate activities and communication. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant Habilitative Therapies.Measurable progress emphasizes accomplishment of functional skills and independence in the context of the Member's potential ability as specified within a care plan or treatment goals. Benefits are subject to the Maximum Benefit Allowance listed in the Schedule of Benefits, Section 1, for each type of therapy under an individual medical plan (IMP) developed for each Member.","EHB",45,"Treatment(s) per Year","Nebraska supplemented this EHB category for Habilitative Services: 'Health care Services that help a person keep, learn, or improve skills and functioning for daily living. These Services may include physical and occupational therapy, speech language pathology and other Services for people with disabilities in a variety of Inpatient and/or Outpatient settings.'  Quantitative limits on services apply to outpatient, only.","EHB",20,"Visit(s) per Benefit Period","20 visits each per PT, OT, ST. Habilitative services include 'services that help you keep, learn or improve skills and functioning for daily living.'  However, though definition includes the term 'keep,' the plan excludes coverage of 'Maintenance Therapy,' defined as 'Treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better.'","EHB",30,"Visit(s) per Year","As required by MHPAEA, the 30 visit limit does not apply to physical therapy, speech therapy, occupational therapy or applied behavior analysis provided to a patient who has autism.","EHB",null,null,null,"EHB",120,"Visit(s) per Year","All Inpatient and Outpatient Short Term Rehabilitation and Habilitative Services are subject to a combined maximum benefit of one hundred twenty (120) days/visits per Member per Calendar Year.","EHB",60,"Visit(s) per Year","Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional's office.","EHB",null,null,"Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include:  (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.","EHB",25,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Year",null,"EHB",36,"Visit(s) per Benefit Period","Limit 36 visits per benefit period for Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, and Respiratory Therapy. Limit 30 visits per benefit period for speech therapy. Combined limit of 30 visits per benefit period for physical therapy and occupational therapy.","EHB",null,null,null,"EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",null,null,"Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period.","EHB",20,"Visit(s) per Year","Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.","EHB",35,"Visit(s) per Year","Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage.","EHB",20,"Visit(s) per Benefit Period","Pre-authorization required only for home visits. Adopt the habilitation therapy definition as, Health care services that help a person keep, learn or improve skills and functioning for daily living which may include physical therapy, occupational therapy, and speech language pathology.","EHB",null,null,"Benefits that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, medical devices, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.  See individual therapy limits.","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.","EHB",null,null,"Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.","EHB",30,"Visit(s) per Benefit Period"]
["Chiropractic Care","EHB",12,"Visit(s) per Year",null,"EHB",600,"Dollars per Year",null,"EHB",30,"Visit(s) per Year","Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; appears to also combine hab and rehab.",null,null,null,null,"EHB",20,"Visit(s) per Year","Coverage includes: a. Evaluation; b. Lab Services and X-rays required for chiropractic Services; and c. Treatment of musculoskeletal disorders.","EHB",20,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period","The following limits apply: three modalities per visit, one visit per day. ","EHB",35,"Visit(s) per Benefit Period","Combined limit for all outpatient therapy plus chiropractic.  ",null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",18,"Visit(s) per Benefit Period",null,"EHB",25,"Visit(s) per Benefit Period",null,"EHB",12,"Visit(s) per Benefit Period","Limit combined In and out of network. Cost share driven by provider/setting.","EHB",null,null,null,"EHB",20,"Treatment(s) per Year",null,"EHB",null,null,null,"EHB",null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.","EHB",20,"Visit(s) per Benefit Period",null,"EHB",40,"Visit(s) per Year","Cost share is driven by provider/setting. Chiropractic Care limit is combined with Manipulative Therapy.","EHB",30,"Visit(s) per Year","Limit combined with OT and PT.","EHB",null,null,"20 visit limit for non-network tier. ","EHB",null,null,"Chiropractic visits beyond 26 per benefit period require Prior Authorization. ","EHB",20,"Visit(s) per Year","Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.","EHB",10,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Benefit Period","30 visit limits for PT and OT combined (including chiropractic).","EHB",20,"Visit(s) per Benefit Period","Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary as determined by BCBSND and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician.","EHB",20,"Visit(s) per Year","Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year.  Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year.","EHB",12,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Year","Referred to as therapeutic manipulation.","EHB",20,"Visit(s) per Year","Unless for Habilitative and Rehabilitative Services","EHB",20,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",12,"Visit(s) per Benefit Period","Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Plan uses the term \"spinal manipulation.\" ","EHB",20,"Visit(s) per Benefit Period",null,"EHB",12,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",20,"Visit(s) per Year","Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for therapy, whether received in a Practitioner's office, outpatient facility or home health setting. ","EHB",35,"Visit(s) per Year","Limited to combined 35 visits per year, including Chiropractic.",null,null,null,null,"EHB",30,"Visit(s) per Benefit Period","Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments.","EHB",null,null,null,"EHB",10,"Visit(s) per Year",null,"EHB",null,null,"Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.","EHB",30,"Visit(s) per Benefit Period",null,"EHB",15,"Visit(s) per Year","Limited to 15 visits per calendar year.","EHB",20,"Visit(s) per Year","HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits.","EHB",null,null,"Coverage is provided for medically necessary spinal manipulation, evaluation, and treatment for the musculoskeletal conditions of the spine when provided by a licensed chiropractor, doctor of osteopathy (D.O.), or other eligible practitioner."]
["Durable Medical Equipment","EHB",null,null,null,"EHB",null,null,"(1) artificial arms and other prosthetics, leg braces, and other orthopedic devices; (2) medical supplies such as oxygen, crutches, casts, catheters, colostomy bags and supplies, and splints.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"When prescribed by a Plan Physician and obtained from sources designated by Health Plan on either a purchase or rental basis, as determined by Health Plan, DME, prosthetics and orthotics, including replacements other than those necessitated by misuse or loss, are provided as shown on the \"Summary Chart\" for your use during the period prescribed. Necessary fittings, repairs and adjustments, other than those necessitated by misuse, are covered. Health Plan may repair or replace a device at its option. Repair or replacement of defective equipment is covered at no additional Charge. You will be charged as a non-Member for items of DME, prosthetics and orthotics until your Deductible is met, if applicable.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).","EHB",null,null,null,"EHB",null,null,"One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment.","EHB",null,null,"Benefits are limited to the amount normally available for a basic (standard) item which allows necessary function. Basic (standard) medical equipment is equipment that provides the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level.  Charges for deluxe or electrically operated medical equipment are not covered, beyond the extent allowed for basic (standard) items. Deluxe describes medical equipment that has enhancements that allow for additional convenience or use beyond that provided by basic (standard) equipment.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"One breast pump per birth (rented or purchased).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per 3 Years","Purchases are limited to a single purchase of a type of DME, including repair and replacement, every three (3) years.","EHB",null,null,null,"EHB",null,null,"Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women's Health and Cancer Rights Act);  Left Ventricular Artificial Devices (LVAD)  covered only as bridge to heart transplant.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Equipment must primarily and customarily serve a medical purpose. Issuer determines whether to pay the rental amount or the purchase price amount for an item and determine the length of any rental term. ","EHB",null,null,"Durable medical equipment over $500 requires prior authorization.","EHB",null,null,null,"EHB",null,null,"DME over $750, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization.","EHB",null,null,"Includes Medical Devices, Orthotics, Medical and Surgical Supplies.  Benefits include equipment and devices (e.g., crutches and customized equipment, Hospital beds and wheelchairs, oxygen concentrator, ventilator, and negative pressure, wound therapy devices). Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. Benefits include repair and replacement costs as well as supplies and equipment needed for the use of the equipment or device, for example, a battery for a powered wheelchair. Oxygen and equipment for its administration are also covered services. Benefits are also available for cochlear implants. Benefits are available for certain types of orthotics (braces, boots, and splints). Covered Services include the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body, or which limits or stops motion of a weak or diseased body part. Also, includes coverage for devices and supplies, such as APAP, CPAP, BPAP and oral devices for sleep treatment, subject to medical necessity. ","EHB",null,null,null,"EHB",null,null,null,"EHB",2500,"Dollars per Year",null,"EHB",null,null,null,"EHB",null,null,"Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment.","EHB",null,null,null,"EHB"]
["Hearing Aids",null,null,null,null,null,null,null,null,null,null,null,"Prosthetic devices to assist hearing or talking devices are not generally covered. Several implantable devices may be covered in certain situations.  ",null,null,null,"Internally-implanted hearing aids are covered as prosthetic devices.","EHB",null,null,null,"EHB",1,"Item(s) per 2 Years",null,"EHB",1,"Item(s) per 3 Years","Benefits are limited to one wearable hearing aid per ear every three (3) years for children less than 24 years of age.",null,null,null,null,null,null,null,"Hearing aids, the fitting of hearing aids or advice on their care; implantable hearing devices are not covered, except for cochlear implants as otherwise stated in this certificate.","EHB",null,null,"1 hearing aid per ear every 60 months.",null,null,null,null,null,null,null,null,"EHB",2,"Visit(s) per 3 Years","Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children.",null,null,null,null,null,null,null,null,"EHB",1,"Item(s) per 3 Years","For adults age 18 or older, limited to $2,800 in Eligible Expenses per year. Benefits are limited to a single purchase (including repair/replacement) per hearing impaired ear every three years. For Enrolled Dependent children under the age of 18, this limit will be one hearing aid, per hearing impaired ear, every 36 months as required by Kentucky insurance law.","EHB",1,"Item(s) per 3 Years","Benefits are available for hearing aids for covered Members age seventeen (17) and under when obtained from a Network Provider or another Provider approved by Us.","EHB",2000,"Dollars per 3 Years","$2,000 for one hearing aid for each hearing impaired ear every 36 months for members 21 years or younger.","EHB",1,"Item(s) per 3 Years","Covered only for Member from birth to age eighteen (18). ","EHB",1,"Item(s) per 3 Years",null,null,null,null,null,"EHB",1,"Item(s) per 3 Years","Coverage includes only external hearing aids for members 18 year old and younger who have hearing loss that is not correctible by other covered procedures. Limited to one hearing aid for each ear every three years. ","EHB",null,null,"Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.",null,null,null,null,null,null,null,"Only for Medically Necessary cochlear implants may be covered per Medical Policy.","EHB",1,"Item(s) per 3 Years","One hearing aid per hearing impaired ear, and replacement hearing aids for members under the age of 22. Once every 36 months.",null,null,null,null,null,null,null,null,"EHB",1,"Item(s) per Procedure","Benefits are available for one hearing aid per ear each time a hearing aid prescription changes.","EHB",1,"Item(s) per 2 Years","One hearing aid per hearing impaired ear per 24-month period.","EHB",1,"Item(s) per 3 Years","Per ear","EHB",1,"Item(s) per 3 Years","Purchases are limited to a single purchase of a type of Hearing Aid, including repair and replacement, once every three (3) years. ","EHB",1,"Item(s) per 3 Years","Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.     ",null,null,null,"Cochlear implants are covered as durable medical equipment.","EHB",null,null,"One hearing aid per ear every 48 months up to age 18.  ","EHB",1,"Item(s) per Year","One hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 36 months as medically necessary for the treatment of a member's hearing loss.  ",null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,"EHB",1,"Item(s) per 3 Years ",null,"EHB",null,null,"To restore or correction of impaired speech or hearing loss. ",null,null,null,null,null,null,null,"This Exclusion does not apply to cochlear implants.","EHB",1,"Item(s) per 3 Years",null,"EHB",null,null,"Cochlear Implants must be covered as they are covered by the state base benchmark plan. ","EHB",2500,"Dollars per Year",null,null,null,null,null,null,null,null,null,"EHB",1,"Item(s) per Benefit Period","Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary by the Medical Management Organization."]
["Imaging (CT/PET Scans, MRIs)","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Precertification is required.","EHB",null,null,null,"EHB",null,null,null,null,null,null,"Benefit provided for outpatient services and when these services are related to surgery or medical.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes x-rays/regular imaging services;  radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QTC Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Preventive Care/Screening/Immunization","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year","GYN exam limited to one exam per calendar year.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"$300 limit per calendar year for non-network tier.","EHB",null,null,null,"EHB",null,null,"Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA.","EHB",null,null,null,"EHB",null,null,"All preventive care that is not state mandated is not covered OON. ","EHB",null,null,"Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Shall include artery calcification testing for the diagnosis of heart disease","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women's contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year","One (1) routine adult physical examination per plan year per member will be covered.","EHB",null,null,"Mammography services, OBGYN exams (limit 2 per year), pap smear services, prostate services, and routine colorectal cancer screening/testing.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covers:  (1) Services with an 'A' or 'B' rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening);  (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to nutrition, and to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription.  Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year","Well Woman and Well Man examinations are limited to 1 visit per year.","EHB"]
["Routine Foot Care","EHB",null,null,"Routine foot care when the member is a diabetic.",null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Only covered for persons diagnosed with diabetes.",null,null,null,null,"EHB",null,null,"Covered when systemic conditions such as metabolic, neurologic, or peripheral vascular disease exists and results in medically significant circulatory deficits or decreased sensation to the foot. ",null,null,null,"This exclusion does not apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided.",null,null,null,"Except for persons who have been diagnosed with diabetes.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Coverage is available if Medically Necessary.","EHB",1,"Visit(s) per Year","Requires a Diabetes diagnosis.","EHB",null,null,"Foot care provided to a Member with diabetes.",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Medically Necessary Routine foot care. ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Benefit is limited to persons being treated for diabetes mellitus",null,null,null,null,"EHB",null,null,"Only for treatment related to diabetic treatment of nerve and circulation disorders of the feet.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not covered except for diabetic patients. "]
["Acupuncture","EHB",12,"Visit(s) per Year","Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.",null,null,null,null,null,null,null,null,"EHB",null,null,"Acupuncture is typically provided only for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain.","EHB",6," Visit(s) per Benefit Period",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not covered unless the treatment is medically necessary and appropriate and is provided within the scope of the acupuncturist's license; and patient is directed to the acupuncturist for treatment by a licensed physician.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",12,"Visit(s) per Year",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Care or treatment by means of acupuncture is excluded except when used as a substitute for other forms of anesthesia.","EHB",20,"Visit(s) per Year","Unless for Habilitative and Rehabilitative Services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",12,"Visit(s) per Year",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Acupuncture exclusion does not apply to Medically Necessary services that would otherwise be Covered services when such services are performed by a naturopath and within the scope of the naturopathic Provider's license.","EHB",12,"Visit(s) per Year"]
["Weight Loss Programs",null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Discounts on such programs are available to the plan members.",null,null,null,null,"EHB",4,"Visit(s) per Year","Nutritional counseling for the treatment of obesity, which includes morbid obesity.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",3,"Months per Year","Your health plan will reimburse you for your costs for up to three months for participation in qualified weight loss program(s) each calendar year. A qualified weight loss program is a hospital-based weight loss program or a non-hospital-based weight loss program designated by Blue Cross Blue Shield HMO Blue.",null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Includes coverage for drugs and programs if medically necessary for morbid obesity and obesity.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Certain weight loss services such as nutritional and diet counseling are available through a diabetes management plan, autism benefits, and for adults at higher risk of chronic disease.",null,null,null,"Services for weight loss or in conjunction with weight loss programs regardless of the medical indications except as allowed under the Affordable Care Act Preventive Services.",null,null,null,null,null,null,null,null,null,null,null,"Nutritional counseling is covered."]
["Routine Eye Exam for Children","EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,"The Benchmark plan covers routine vision screenings that are preventive care services.  Pediatric Vision services are an EHB and are generally covered by plans pursuant to benefits offered under the Federal Employees Dental and Vision Insurance Program vision plan. ","EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",1,"Exam(s) per Benefit Period",null,"EHB",null,null,null,"EHB",1,"Exam(s) per Benefit Period",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year","1 exam(s) per calendar year with no cost-sharing.","EHB",1,"Exam(s) per Benefit Period",null,"EHB",1,"Exam(s) per Year","One eye exam every 12 months from last date of service. ","EHB",1,"Exam(s) per Year",null,"EHB",null,null,"$300 limit per calendar year for non-network tier.","EHB",1,"Exam(s) per Benefit Period",null,"EHB",1,"Exam(s) per Benefit Period",null,"EHB",1,"Visit(s) per Benefit Period","The following services only may be provided by a licensed ophthalmologist or optometrist operating within the scope of his or her license, or a dispensing optician to Members under 19 years of age: One Routine vision exam per Benefit Period. ","EHB",1,"Exam(s) per Benefit Period",null,"EHB",1,"Exam(s) per Benefit Period",null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,"This Plan covers a complete eye exam with dilation, as needed.","EHB",1,"Exam(s) per Year","Covers vision screening for Dependent children, through age 17.","EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",1,"Exam(s) per Year",null,"EHB",1,"Exam(s) per Year","Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.","EHB",1,"Exam(s) per Year",null,"EHB",null,null,"Supplemented with FEP BlueVision - High Option.","EHB",1,"Exam(s) per Year",null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Exam(s) per Benefit Period",null,"EHB",null,null,null,"EHB",1,"Visit(s) per Benefit Period",null,"EHB",1,"Exam(s) per Benefit Period","Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together.","EHB",1,"Visit(s) per Year",null,"EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",1,"Exam(s) per Year",null,"EHB",1,"Exam(s) per Year","Covers one exam per calendar year subject to deductible and coinsurance.","EHB",null,null,null,"EHB",1,"Exam(s) per Benefit Period"]
["Eye Glasses for Children","EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per Year",null,"EHB",null,null,"Special contact lenses for aniridia, and for Aphakia up through age 9, are covered.  Otherwise, pediatric vision services are covered pursuant to the benefits offered under the Federal Employees Dental and Vision Insurance Program vision plan. ","EHB",1,"Item(s) per 2 Years","1 pair every 24 months includes the frames and lenses or contact lenses.","EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Year",null,"EHB",null,null,null,"EHB",1,"Item(s) per Year",null,"EHB",null,null,null,"EHB",1,"Item(s) per Benefit Period",null,"EHB",null,null,null,"EHB",1,"Item(s) per Benefit Period",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per Year","Benefits are also provided for the coverage of one pair of replacement eyeglasses every 12 months or repair of lenses and/or frames when medically necessary.","EHB",null,null,null,"EHB",1,"Item(s) per Year   ","1 pair eyeglasses per calendar year with no cost-sharing for a 'Collection Frame'; or $150 allowance + 20% off expense beyond allowance.  Contact lenses once per year in lieu of eyeglasses; $150 allowance toward lenses + 15% off expense beyond allowance.   ","EHB",1,"Item(s) per Benefit Period",null,"EHB",1,"Item(s) per 2 Years","Child frames and lenses or contact lenses covered once every 24 months.","EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Year","Covered lenses and frames each available at limit of one per year.  ","EHB",1,"Item(s) per Benefit Period",null,"EHB",1,"Item(s) per Benefit Period"," One pair of glasses (frames and lenses) or one pair of contacts per Benefit Period.","EHB",1,"Item(s) per Benefit Period",null,"EHB",1,"Item(s) per Benefit Period ","Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period.  ","EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Benefit Period",null,"EHB",1,"Item(s) per Year","Vision benefits described in this provision for Covered Persons through age 18. We cover one pair of lenses, for glasses or contact lenses, and one pair of frames.","EHB",null,null,null,"EHB",1,"Item(s) per Year","Covers one (1) pair of lenses once every calendar year when a prescription change is determined Medically Necessary; One (1) pair of frames. ","EHB",1,"Item(s) per Year","One prescribed lenses & frames in a 12-month period.","EHB",1,"Item(s) per Year","Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.","EHB",1,"Item(s) per Year",null,"EHB",null,null,"Supplemented with FEP BlueVision - High Option.","EHB",1,"Item(s) per Year",null,"EHB",1,"Exam(s) per Benefit Period","Supplemented with FEP Blue Vision Plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per Benefit Period",null,"EHB",null,null,null,"EHB",1,"Item(s) per Benefit Period","Lenses only.","EHB",1,"Item(s) per Benefit Period","Includes a choice of eyeglass lenses with factory scratch coating or contact lenses in one benefit period. Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in: Single vision; Bifocal; Trifocal (FT 25-28); and Progressive.  Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses.  Non-elective contact lenses are covered only for the following medical conditions: Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard spectacle lenses; High Ametropia exceeding -12D or +9D in spherical equivalent; Anisometropia of 3D or more; when your vision can be corrected three lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses.","EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Year","Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses).","EHB",null,null,null,"EHB",1,"Item(s) per Year",null,"EHB",1,"Item(s) per Year","Covers one pair of eyeglasses or 12 month supply of contacts per calendar year. ","EHB",null,null,null,"EHB",1,"Item(s) per Benefit Period"]
["Dental Check-Up for Children","EHB",null,null,null,"EHB",null,null,null,"EHB",2,"Visit(s) per 6 Months",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2,"Visit(s) per Year",null,"EHB",1,"Visit(s) per 6 Months",null,"EHB",null,null,null,"EHB",2,"Procedure(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",2,"Exam(s) per Year","Comprehensive - once per member per provider.  Periodic - 2 per calendar year. Limited Oral evaluation - 2 per calendar year.  Oral evaluation for members under 3 years. ","EHB",2,"Exam(s) per Benefit Period",null,"EHB",null,null,null,"EHB",2,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2000,"Dollars per Year",null,"EHB",null,null,null,"EHB",2,"Visit(s) per Benefit Period",null,"EHB",2,"Exam(s) per Benefit Period",null,"EHB",2,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Visit(s) per 6 Months",null,"EHB",1,"Exam(s) per 6 Months",null,"EHB",1,"Exam(s) per 6 Months","Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.","EHB",2,"Visit(s) per Year",null,"EHB",null,null,"Supplemented with OHP Plus.","EHB",1,"Exam(s) per 6 Months",null,"EHB",2,"Visit(s) per Benefit Period","Supplemented with FEDVIP MetLife Dental Plan.","EHB",1,"Visit(s) per 6 Months",null,"EHB",null,null,null,"EHB",1,"Exam(s) per 6 Months",null,"EHB",null,null,null,"EHB",2,"Procedure(s) per Benefit Period","Routine cleaning, exams, x-rays and fluoride. Sealants once every five years.","EHB",1,"Treatment(s) per 6 Months","Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208.","EHB",null,null,"Class I services including examinations and cleanings.","EHB",2,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",2,"Visit(s) per Year",null,"EHB",1,"Visit(s) per 6 Months","Limited to one every six months. ","EHB",null,null,null,"EHB",2,"Procedure(s) per Benefit Period"]
["Rehabilitative Speech Therapy","EHB",45,"Visit(s) per Year","Visit limit for physical, speech, and occupational therapy services combined.","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; appears to also combine hab and rehab.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Speech therapy is limited to treatment for speech impairments due to injury or illness. Many pediatric conditions do not qualify for coverage because they lack a specific organic cause and may be long term and chronic in nature. Covered if, in the judgement of a Plan Physician, significant improvement is achievable within a two-month period. ","EHB",40,"Visit(s) per Year","Limit includes PT, ST and OT.","EHB",30,"Visit(s) per Benefit Period","Must be needed to needed to improve speech problems caused by disease, trauma, congenital defect, or recent surgery.","EHB",35,"Visit(s) per Benefit Period","Combined limit for all outpatient therapy plus chiropractic.  ","EHB",40,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",20,"Visit(s) per Benefit Period",null,"EHB",null,null,"When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).","EHB",20,"Visit(s) per Benefit Period","Combined In and out of network. Cost share driven by provider/setting.","EHB",90,"Days per Benefit Period","Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.","EHB",25,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",30,"Visit(s) per Benefit Period","30 visits each per injury or illness per benefit period for each of OT, PT, and ST.","EHB",20,"Visit(s) per Year","Rehabilitation and habilitation covered with shared limits for speech therapy.  20 visits combined for speech therapy. Cost share driven by provider/setting.","EHB",30,"Visit(s) per Year",null,"EHB",null,null,"20 visit limit for non-network tier.","EHB",null,null,"Unlimited visits for speech therapy.","EHB",20,"Visit(s) per Year","Not covered for learning disabilities and development problems.","EHB",null,null,"Also an Outpatient Therapies benefit.","EHB",30,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Year","Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Limit is combined for rehabilitation and habilitation services. ","EHB",45,"Visit(s) per Year","Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).","EHB",20,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",120,"Visit(s) per Year","All Inpatient and Outpatient Short Term Rehabilitation and Habilitative Services are subject to a combined maximum benefit of one hundred twenty (120) days/visits per Member per Calendar Year.","EHB",60,"Visit(s) per Year","60 visits per condition per year combined.  Speech therapy is only covered following a hospital stay or surgery.","EHB",20,"Visit(s) per Benefit Period",null,"EHB",25,"Visit(s) per Benefit Period","Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).","EHB",30,"Visit(s) per Year","30 visits per condition per calendar year.","EHB",30,"Visit(s) per Benefit Period","Includes treatment for the correction of a speech impairment resulting from disease, Surgery, injury, congenital anomalies, or previous therapeutic processes. Coverage will also include services by a speech therapist.","EHB",null,null,null,"EHB",30,"Visit(s) per Benefit Period",null,"EHB",null,null,"Coverage includes rehabilitative speech therapy services when related to a specific illness, injury, or impairment and involve the mechanics of phonation, articulation, or swallowing. Services must be provided by a licensed or certified speech pathologist.","EHB",20,"Visit(s) per Year","Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.","EHB",null,null,null,"EHB",20,"Visit(s) per Benefit Period","Pre-authorization required only for home visits.","EHB",30,"Visit(s) per Benefit Period","Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment.  Limit does not apply when received as part of hospice benefit or early intervention benefit.","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services.","EHB",20,"Visit(s) per Year","Rehabilitative services must be short term.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.","EHB",60,"Visit(s) per Year","Visit limit is for all therapy types combined (PT, OT, ST).","EHB"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy","EHB",45,"Visit(s) per Year","Visit limit for physical, speech, and occupational therapy services combined.","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","60 inpatient days/year. 30 visit limit is combined with PT, OT, speech and chiro.","EHB",null,null,null,"EHB",20,"Visit(s) per Year","Covered if, in the judgement of a Plan Physician, significant improvement is achievable within a two month period. 60-day limit for inpatient rehab. ","EHB",40,"Visit(s) per Year","Limit includes PT, ST and OT.","EHB",30,"Visit(s) per Benefit Period","Must be needed to help your condition improve in a reasonable and predictable time, or needed to establish an effective home exercise program.","EHB",35,"Visit(s) per Benefit Period","Combined limit for all outpatient therapy plus chiropractic.  ","EHB",40,"Visit(s) per Year",null,"EHB",null,null,"The therapy is short-term, generally not longer than 90 days. ","EHB",null,null,null,"EHB",20,"Visit(s) per Benefit Period",null,"EHB",null,null,"Maintenance Speech Therapy is not covered.","EHB",40,"Visit(s) per Benefit Period","Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services.","EHB",null,null,null,"EHB",25,"Visit(s) per Year","25 visits of physical therapy. 25 visits of occupational therapy.","EHB",null,null,null,"EHB",60,"Visit(s) per Year","60 visits combined outpatient physical and occupational therapy.","EHB",30,"Visit(s) per Benefit Period","30 visits each per injury or illness per benefit period for each of OT, PT, and ST.","EHB",20,"Visit(s) per Year","Rehabilitation and habilitation covered with shared limits for occupational and physical therapy.  20 visits combined for occupational and physical therapy. Cost share driven by provider/setting.","EHB",30,"Visit(s) per Year","Combined with chiro.","EHB",null,null,"20 visit limit for non-network tier.","EHB",20,"Visit(s) per Benefit Period","20 visit limit each for PT and OT.","EHB",20,"Days per Year","The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.","EHB",null,null,"Also an Outpatient Therapies benefit.","EHB",30,"Visit(s) per Benefit Period","Combined 30 visit limit for occupational and physical therapies and chiropractic services.","EHB",30,"Visit(s) per Year","Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness.  30-visit limit is for each of PT, OT, and ST, rehab and hab combined.  Benefits are not available for Maintenance Care.","EHB",45,"Visit(s) per Year","Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).","EHB",20,"Visit(s) per Benefit Period",null,"EHB",30,"Visit(s) per Year","Coverage for occupational therapy and physical therapy combined is limited to 30 visits per Calendar Year.","EHB",null,null,null,"EHB",120,"Visit(s) per Year","All Inpatient and Outpatient Short Term Rehabilitation and Habilitative Services are subject to a combined maximum benefit of one hundred twenty (120) days/visits per Member per Calendar Year.","EHB",60,"Visit(s) per Year","60 visits per condition per year combined.  Physical therapy is only covered following a hospital stay or surgery.","EHB",40,"Visit(s) per Benefit Period","Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. ","EHB",25,"Visit(s) per Benefit Period","Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period","Occupational Therapy: Coverage will also include services rendered by a registered, licensed occupational therapist. The Member is required to have these services performed by the Member's Primary Care Physician's Designated Provider. Physical Therapy: Includes treatment by physical means, heat, hydrotherapy or similar modalities, physical agents, bio- mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, injury, or loss of body part. The Member is required to have these services performed by the Member's Primary Care Physician's Designated Provider.","EHB",null,null,"Preauthorization is recommended for the eleventh (11th) and subsequent visits.","EHB",30,"Visit(s) per Benefit Period",null,"EHB",null,null,"Occupational therapy is only covered insofar as services to treat the upper extremities, which means the arms from the shoulders to the fingers.","EHB",20,"Visit(s) per Year","Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.","EHB",null,null,null,"EHB",20,"Visit(s) per Benefit Period","Pre-authorization required only for home visits.","EHB",30,"Visit(s) per Benefit Period","Includes treatment to restore a physically disabled person's ability to do activities of daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a bed, bathing, and therapy for tasks needed for the person's job. Also, includes the treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg by means of hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices. Limit is combined for physical and occupational therapy habilitative and rehabilitative. Limit does not apply when received as part of hospice benefit or early intervention benefit.  ","EHB",30,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Year","Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services.","EHB",20,"Visit(s) per Year",null,"EHB",30,"Visit(s) per Benefit Period","30 visit each for Occupational and Physical Therapies.","EHB",60,"Visit(s) per Year","Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.","EHB",60,"Visit(s) per Year","Visit limit is for all therapy types combined (PT, OT, ST).","EHB"]
["Well Baby Visits and Care","EHB",null,null,null,"EHB",9,"Visit(s) per 2 Years","Well baby visits are covered for the child's first two years.","EHB",null,null,null,"EHB",null,null,"Well-child preventive exams are covered for Members through age 23 months.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Care provided for birth through age 5.","EHB",null,null,null,"EHB",null,null,"Covered for child through age 7.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covered under Inpatient Hospital benefits.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Well Child Care to the Member's 6th birthday, 100% of Allowed Charge. Deductible Amount is waived.  For baby includes 7 visits for Members from birth through 12 months. ","EHB",null,null,null,"EHB",null,null,"Covered under preventive care.","EHB",null,null,"Under preventive care.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefit should mirror preventive care/screening/immunization. ","EHB",null,null,"Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening). ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.","EHB"]
["Laboratory Outpatient and Professional Services","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefit provided for outpatient services and when these services are related to surgery or medical care.","EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["X-rays and Diagnostic Imaging","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefit provided for outpatient services and when these services are related to surgery or medical care.","EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine. ","EHB",null,null,"Health plans may require Prior Approval for special radiology procedures (including CT, MRI, MRA, MRS, PET scans, and echocardiograms), polysomnography (sleep studies) as determined by the plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Basic Dental Care – Child","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pediatric dental services are considered an EHB and are covered by plans pursuant to the Health Families 2011-2012 CHIP benefits. ","EHB",null,null,"Diagnostic and Preventive Limitations 1. Prophylaxis (cleaning) is a benefit only ONCE in a 12 month period. 2. Oral evaluations (exams) are a benefit twice in a 12 month period. 3. Topical fluoride application is a benefit twice in a 12 month period. 4. Bitewing x-rays are a benefit only ONCE in a 12 month period and are not a benefit in addition to a complete mouth series. Complete mouth x-rays are a benefit only once in sixty (60) months. 5. Space maintainer is a benefit only for premature loss of deciduous (baby) posterior (back) teeth. 6. Sealant Benefits include the application of sealants only to permanent molar teeth with the occlusal surfaces intact, no caries (decay), and/or with no restorations. 7. Separate benefit shall not be made for any preparation or conditioning of the tooth or any other procedure associated with sealant application. 8. Sealant Benefits do not include any repair or replacement of a sealant on any tooth within thirty-six (36) months of its application. Such repair or replacement done by the same dentist is considered included in the fee for the initial placement of the sealant.","EHB",null,null,null,"EHB",1,"Visit(s) per 6 Months","Should cover 1 visit every six months.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2000,"Dollars per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Visit(s) per 6 Months",null,"EHB",1,"Exam(s) per 6 Months","One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.","EHB",null,null,"Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.","EHB",null,null,null,"EHB",null,null,"Supplemented with OHP Plus.","EHB",null,null,null,"EHB",null,null,"Supplemented with FEDVIP MetLife Dental Plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Benefit limitations may apply to individual services.","EHB",null,null,"Class II (basic) services including simple restoration (fillings), crowns and jackets, repair of crowns, wisdom tooth removal, extractions, and endodontics (root canal).","EHB",1,"Exam(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Orthodontia – Child","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Dental and orthodontic services for cleft palate, if services are integral part of reconstructive surgery for cleft palate covered under reconstructive surgery by the Benchmark Plan, a plan provider or authorized non-plan provider who is a dentist or orthodontist provides the services. ",null,null,null,null,"EHB",null,null,"Medically necessary services only.","EHB",null,null,"Covered Services, which are intended to treat a severe dental abnormality and are the only method capable of preventing irreversible damage to the Member's teeth or their supporting structures, and restoring the Member's oral structure to health and function.","EHB",null,null,null,"EHB",null,null,"Only covers orthodontic treatment for a congenital anomaly related to or developed as a result of cleft palate, with or without cleft lip.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Limitations vary based on procedures.","EHB",null,null,null,"EHB",null,null,"Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time.","EHB",null,null,null,"EHB",null,null,null,null,null,null,"Medically necessary orthodontia covered.","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Orthodontia for children is only covered when medically necessary.  ","EHB",null,null,null,"EHB",1,"Treatment(s) per Lifetime","Only for the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Coverage provided for Medically Necessary Services only.","EHB",null,null,null,"EHB",null,null,"Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.","EHB",null,null,null,"EHB",null,null,"Supplemented with OHP Plus.","EHB",24,"Months per Lifetime","Orthodontic treatment must be Medically Necessary.","EHB",null,null,"Supplemented with FEP Blue Vision Plan for medically necessary orthodontia.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",1,"Treatment(s) per Lifetime","Limit applies to one comprehensive orthodontic treatment of the adolescent dentition.","EHB",null,null,"Orthodontia Medically Necessary for the treatment of a medical condition is covered.","EHB",null,null,"Medically necessary orthodontia must be covered.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Treatment(s) per Lifetime","Braces once per lifetime."]
["Major Dental Care – Child","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Dental services for radiation treatment. Dental Anesthesia for children under age 7, developmentally disabled, or compromised health and patient's clinical status/medical condition requires dental procedure be provided in hospital or outpatient surgery center and the procedure would not ordinarily require general anesthesia.","EHB",null,null,"Diagnostic and Preventive Limitations 1. Prophylaxis (cleaning) is a benefit only ONCE in a 12 month period. 2. Oral evaluations (exams) are a benefit twice in a 12 month period. 3. Topical fluoride application is a benefit twice in a 12 month period. 4. Bitewing x-rays are a benefit only ONCE in a 12 month period and are not a benefit in addition to a complete mouth series. Complete mouth x-rays are a benefit only once in sixty (60) months. 5. Space maintainer is a benefit only for premature loss of deciduous (baby) posterior (back) teeth. 6. Sealant Benefits include the application of sealants only to permanent molar teeth with the occlusal surfaces intact, no caries (decay), and/or with no restorations. 7. Separate benefit shall not be made for any preparation or conditioning of the tooth or any other procedure associated with sealant application. 8. Sealant Benefits do not include any repair or replacement of a sealant on any tooth within thirty-six (36) months of its application. Such repair or replacement done by the same dentist is considered included in the fee for the initial placement of the sealant.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Limitations vary based on procedures.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",2000,"Dollars per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.","EHB",null,null,null,"EHB",null,null,"Supplemented with OHP Plus.","EHB",null,null,null,"EHB",null,null,"Supplemented with FEDVIP MetLife Dental Plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Benefit limitations may apply to individual services.","EHB",null,null,"Class III (major) services including dentures, bridges, replacement of bridges and dentures, and Medically Necessary orthodontia; and/or Facility and anesthesia charges are covered to the extent required by 8 V.S.A. section 4100i for all Covered Persons.","EHB",null,null,"Quantitative limits apply; see EHB base benchmark plan.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Basic Dental Care – Adult",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Basic dental care for adults not covered by CHIP. ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"See Accidental Dental benefit for additional information."]
["Orthodontia – Adult",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Orthodontia for cleft palate as described above. ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"See Accidental Dental benefit for additional information."]
["Major Dental Care – Adult",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Dental services for radiation treatment.  Dental Services for cleft palate as described above. ",null,null,null,null,null,null,null,"Covered only where required by CGS 38a-491a and/or 38a-517a.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Major dental care for adults not covered by CHIP.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"See Accidental Dental benefit for additional information.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Facility and anesthesia charges are covered to the extent required by 8 V.S.A. section 4100i for all Covered Persons."]
["Abortion for Which Public Funding is Prohibited",null,null,null,null,null,null,null,null,null,null,null,"Pregnancy terminations under the direction of a Physician are covered, but only when performed in an In-Network Hospital or In Network Outpatient Hospital setting.",null,null,null,null,null,null,null,"Voluntary, elective abortions and any related Services, drugs or supplies are excluded. Exceptions to this are: 1. When an abortion is Medically Necessary to preserve the life or health of the mother if the pregnancy continues to term; or 2. When the pregnancy is the result of an act of rape or incest; or 3. Treatment of complications following an abortion.",null,null,null,null,null,null,null,"Plan covers non-elective abortions necessary to avert the death of the member or to terminate pregnancies caused by rape or incest.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Covered only when the life of the mother is at risk.",null,null,null,"To preserve the life of the female upon whom the abortion is performed.",null,null,null,"Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.",null,null,null,"Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman's death or a substantial and irreversible impairment of a major bodily function of the pregnant woman.",null,null,null,"Covered when life of the mother is in jeopardy.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefits include only services for a 'therapeutic abortion,' which is an abortion performed to save the life of the mother.  Public funding is not prohibited when an abortion is performed to save the life of the mother.   ",null,null,null,"Limited to medically necessary abortion required in order to preserve the life or physical health of the mother.",null,null,null,"Elective termination of pregnancy, except in the instances of endangerment of the mother's life, rape or incest.",null,null,null,null,null,null,null,"Excludes Abortions, except for those necessary to prevent the death of the woman. No benefits are available for removal of all or part of a multiple gestation.",null,null,null,null,null,null,null,"Covers both 'therapeutic' and elective, including rape/incest.","EHB",null,null,"The policy provides coverage for medically necessary and appropriate surgery.  Abortion is surgery and to the extent it is medically necessary and appropriate for the patient, is covered.  ",null,null,null,null,null,null,null,"Elective abortions are not covered.",null,1,"Procedure(s) per Year","Coverage for therapeutic abortion and non-therapeutic abortions. Limited to one elective abortion per member per calendar year.",null,null,null,"Coverage for nontherapeutic abortion is prohibited for Qualified Health Plans per Ohio Revised Code section 3901.87.",null,null,null,"When the mother's life or health is endangered.",null,null,null,null,null,null,null,"Elective Abortion: The Health Benefit Plan will provide coverage for services provided in a Participating Facility Provider that is a Hospital or Birth Center. It also includes services performed by a Referred Specialist for the voluntary termination of a pregnancy by a Member.",null,null,null,null,null,null,null,null,null,null,null,"Plan covers complications of pregnancy such as an ectopic pregnancy that is terminated or a spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible.",null,null,null,"Covers Medically Necessary and Appropriate termination of a pregnancy.",null,null,null,null,null,null,null,null,null,null,null,"Pursuant to Virginia law no QHP sold or offered on an exchange shall provide coverage for abortions, provided that this limitation shall not apply to an abortion performed (i) when the life of the mother is endangered by a physical disorder, physical illness, or physical injury, including a life endangering physical condition relating to the pregnancy, or (ii) when the pregnancy is the result of rape or incest.",null,null,null,"Abortion and any related services, drugs, or supplies are covered.",null,null,null,"Coverage includes termination of pregnancy for all female members.",null,null,null,null,null,null,null,"Non-elective abortions are Covered Services.",null,null,null,"Therapeutic or elective termination of pregnancy prior to full term.",null,null,null,"Voluntary termination of pregnancy' is excluded."]
["Transplant","EHB",75000,"Dollars per Lifetime","Quantitative limit on Donor costs only. The types of solid organ transplants and bone marrow/stem cell reinfusion procedures that currently meet the plan's criteria for coverage are: Heart, Heart/double lung, single lung, Double lung, Liver, Kidney, Pancreas, Pancreas with kidney, Bone marrow (autologous and allogenic), Stem cell (autologous and allogeneic).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Coverage will cease if it is determined that patient does not qualify for a transplant.","EHB",null,null,"Transplants are covered on a LIMITED basis as follows: a. Covered transplants are limited to: kidney transplants; heart transplants; heart-lung transplants; liver transplants; liver transplants for children with biliary atresia and other rare congenital abnormalities; small bowel transplants; small bowel and liver transplants; lung transplants; cornea transplants; simultaneous kidney-pancreas transplants; and pancreas alone transplants. b. Bone marrow transplants (autologous stem cell or allogeneic stem cell) associated with high dose chemotherapy for germ cell tumors and neuroblastoma in children and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich syndrome. c. If all medical criteria developed by the health plan are met, we cover: stem cell rescue; and transplants of organs, tissue or bone marrow.","EHB",null,null,null,"EHB",null,null,"Except for kidney and bone marrow/stem cell transplants, the maximum benefit for organ harvesting and procurement is $10,000 for each cadaveric organ and up to $45,000 for each organ procured from a living donor (including harvesting). Maximums are subject to copayments, deductibles and coinsurance, if any. If there are no BDCT facilities for kidney transplants, living donor costs are limited to $50,000 (not including harvesting).","EHB",null,null,null,"EHB",10000,"Dollars per Procedure","Limited to a combined maximum of $10,000 per covered organ transplant.","EHB",null,null,null,"EHB",null,null,"Transplants are subject to Case Management.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).","EHB",null,null,"Benefits are provided for the following human organ transplants: Cornea; heart; heart-lung; kidney; pancreas; liver; lung (whole or lobar, single or double); small intestine; and multivisceral transplants. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"If both the donor and the recipient are covered Members Benefits provided to cover both patients for organ and tissue transplants; If the recipient is a Member under a Contract but the donor is not, Benefits provided for both the recipient and donor as long as similar Benefits are not available to the donor from other sources; If the recipient is not a Member under a Contract but the donor is a Member, no Benefits to either the donor or the recipient. Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Prior authorization is required. No benefits will be provided unless Network provider receives prior authorization from Company.","EHB",null,null,null,"EHB",null,null,"Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. ","EHB",1,"Exam(s) per Transplant","One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"If the donor does not have health coverage that would cover the costs associated with his or her role as donor, this Policy will cover the donor's medical costs associated with the donation.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covers heart, lung, liver, small intestines-pancreas, kidney, cornea, small bowel and bone marrow.","EHB",null,null,null,"EHB",null,null,"Transplants are subject to Case Management. ","EHB",null,null,"Transplant services or supplies that have not received Prior Authorization will not be Covered.","EHB",null,null,"Preauthorization is required.","EHB",null,null,null,"EHB",null,null,"Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies.  When a human organ transplant is provided from a living donor to a covered member, both the recipient and the donor may receive benefits.  ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services. ","EHB",null,null,"Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. ","EHB",null,null,"Transplants and related services must be coordinated and prior authorization must be obtained from CareFirst. Prior authorization is not required for cornea transplants and kidney transplants. "]
["Accidental Dental","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.","EHB",null,null,null,"EHB",3000,"Dollars per Episode","The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.","EHB",null,null,"Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions). ","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"$300 limit per calendar year for non-network tier. Treatment/restoration must be initiated within 6 months of date of injury. Coverage is limited to initial course of treatment and/or initial restoration. Services must be provided within 24 months of date of injury. ","EHB",3000,"Dollars per Episode","Treatment must begin within 12 months of the injury.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"An accidental injury is defined as an injury that is the result of an external force causing a specific impairment to the jaw, sound natural teeth, dentures, mouth or face. Covered Services must be initiated within 6 months of the date of injury and completed within 24 months of the start of treatment or longer if a dental treatment plan approved by BCBSND is in place.     ","EHB",null,null,null,"EHB",null,null,"Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury.","EHB",null,null,"Horizon BCBSNJ also covers treatment of an Injury to natural teeth or the jaw, but only if: a) the Injury was not caused, directly or indirectly by biting or chewing; and b) all treatment is finished within 6 months of the date of the Injury. Treatment includes replacing natural teeth lost due to such Injury. ","EHB",null,null,null,"EHB",null,null,"Covered when treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days. ","EHB",null,null,null,"EHB",3000,"Dollars per Episode","Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient's medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The initial treatment of Accidental Injury/trauma (That is, fractured facial bones and fractured jaws), in order to restore proper function. Restoration of proper function includes the dental services required for the initial restoration or replacement of Sound Natural Teeth, required for the initial treatment for the Accidental Injury/trauma.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Treatment must be completed within 12 months of the injury. ","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident.  Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service.   ","EHB",null,null,"The following services are covered for Covered Persons over age 21: treatment for, or in connection with, an accidental injury to jaws, sound natural teeth, mouth or face, provided a continuous course of dental treatment begins within six months of the accident; surgery to correct gross deformity resulting from major disease or Surgery (Surgery must take place within six months of the onset of disease or within six months after Surgery, except as otherwise required by law); surgery related to head or neck cancer where sound natural teeth may be affected primarily or as a result of the chemotherapy or radiation treatment of that cancer; treatment for a congenital or genetic disorder, such as but not limited to the absence of one or more teeth, up to the first molar, or abnormal enamel; and facility and anesthesia charges for Covered Persons with severe disabilities that preclude office-based dental care due to safety considerations.",null,null,null,null,"EHB",3000,"Dollars per Year",null,"EHB",null,null,null,"EHB",null,null,"Pediatric only - Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product.","EHB",null,null,"Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.","EHB",null,null,"Only medically necessary dental services such as restoration of the tooth or teeth or the initial placement of a bridge or denture to replace the tooth or teeth injured or lost as a direct and sole result of the accidental bodily injury is covered."]
["Dialysis","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Dialysis services are covered if they meet the plans listed criteria.","EHB",null,null,"Dialysis services related to acute renal failure and end-stage renal disease are covered if the following criteria are met: 1. The Services are provided inside our Service Area; and 2. You meet all medical criteria developed by the health plan and by the facility providing the dialysis; and 3. The facility is certified by Medicare and contracts with the health plan; and 4. A Plan Physician provides a written referral for care at the facility.","EHB",null,null,"If needed carrier may develop explanations pertinent in defining the benefit attributes.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Plan cover Hemodialysis.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covered 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-dialysis.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits include supportive use of an artificial kidney machine.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Dialysis treatment when provided in the Outpatient facility of a Hospital, a free-standing renal Dialysis facility or in the home. In the case of home Dialysis, Covered Services will include equipment, training, and medical supplies.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes services for acute renal failure and chronic (end-stage) renal disease, including hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis (CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Dialysis treatments can be rendered in an outpatient dialysis Facility, doctor's office, or home dialysis and training for the covered person and the person who will help with home self-dialysis.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Allergy Testing","EHB",null,null,null,"EHB",200,"Dollars per Year",null,"EHB",null,null,"SOB includes 'allergy services.'","EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,"Allergy testing and treatment.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"This benefit also includes injections. Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefit includes serum, direct skin testing and patch testing when ordered by a Professional Health Care Provider and performed in accordance with medical guidelines and criteria established by BCBSND. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The policy covers non-surgical care and treatment which includes diagnostic services.  Allergy testing is covered as a diagnostic service.  ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials.  ","EHB",null,null,"Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Charges for office visits in connection with repetitive injections are not covered.  Sublingual or colorimetric allergy testing. ","EHB",null,null,"Includes benefits for medically necessary allergy testing and treatment, including allergy serum and allergy shots.","EHB",null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB"]
["Chemotherapy","EHB",null,null,null,"EHB",null,null,"Covered under, Inpatient, Outpatient, and Physician Services.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"\"Orally administered anti-cancer medication\" covered even under basic drug option.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"High-dose chemotherapy to support transplant procedures.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Chemotherapeutic agents, if administered intravenously or intramuscularly (through intraarterial injection, infusion, perfusion or subcutaneous, intracavitary and oral routes) will be covered.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Covered under the base benchmark plan.","EHB",null,null,"Intravenous chemotherapy is covered.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Radiation","EHB",null,null,null,"EHB",null,null,"Covered under, Inpatient, Outpatient, and Physician Services.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Radioactive materials used for therapeutic purposes.","EHB",null,null,null,"EHB",null,null,"Radiation therapy is covered for cancer and neoplastic diseases.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes treatment (tele therapy, brachytherapy and intraoperative radiation, photon or high-energy particle sources), materials and supplies needed, administration, and treatment planning.","EHB",null,null,null,"EHB",null,null,"Covered under the base benchmark plan; covered under applicable benefit (such as office visit).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB"]
["Diabetes Education","EHB",null,null,null,"EHB",null,null,"Covered under disease management, which includes education.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",10,"Hours per Lifetime","If needed carrier may develop explanations pertinent in defining the benefit attributes.  AHCT disagrees the limit is per life time. The limit per the document is up to 10 hrs initial training and up to 8 additional hrs under other circumstances.",null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.","EHB",null,null,null,"EHB",null,null,"Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Visit(s) per Year",null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.","EHB",null,null,null,"EHB",3,"Hours per Year","Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis.","EHB",null,null,"When prescribed by a Participating Professional Provider legally authorized to prescribe such items under law, the Health Benefit Plan will provide coverage for diabetes Outpatient self management training and education, including medical nutrition.","EHB",null,null,null,"EHB",null,null,"Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes.","EHB",null,null,"Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Must be for the diagnosis of diabetes.","EHB",null,null,"Includes education for diabetes care for all diabetics, including outpatient self-management training and education performed in-person; medical nutrition therapy, when provided by a certified, licensed, or registered health care professional. Diabetic education may be received from pharmacies that are authorized to perform this service.","EHB",null,null,"As required by 8 V.S.A. section 4089c, coverage includes equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin using diabetes, gestational diabetes, and non-insulin using diabetes.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per Lifetime","Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis. ","EHB",null,null,null,"EHB"]
["Prosthetic Devices","EHB",null,null,"Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition.","EHB",null,null,"Artificial arms and other prosthetics, leg braces, and other orthopedic devices.","EHB",null,null,null,"EHB",null,null,"The following prosthetic and orthotic devices are covered: internally implanted devices such as pacemakers, intraocular lenses, cochlear implants, osseointegrated hearing devices, hip joints, if implanted during a surgery the plan is covering; prosthetic devices/installation accessories to restore method of speaking following removal of larynx;  prostheses needed after Medically Necessary mastectomy & three brassieres required to hold prosthesis every 12 months; compression burn garments and lymphedema wraps and garments; enteral formula for members who require tube feeding w/in Medicare guidelines; prostheses to replace all or part of external facial body part removed or impaired as result of disease, injury, or congenital defect.","EHB",null,null,"The following prosthetic devices are covered, including repairs, adjustments and replacements other than those necessitated by misuse or loss, when prescribed by a Plan Physician and obtained from sources designated by Health Plan: i. Internally implanted devices for functional purposes, such as pacemakers and hip joints. ii. Prosthetic devices for Members who have had a mastectomy. The Health Plan will designate the source from which external prostheses can be obtained. Replacement will be made when a prostheses is no longer functional. Custom-made prosthesis will be provided when necessary. iii. Prosthetic devices, such as obturators and speech and feeding appliances, required for treatment of cleft lip and cleft palate in newborn Members when prescribed by a Plan Physician and obtained from sources designated by Health Plan. iv. Prosthetic devices intended to replace, in whole or in part, an arm or leg when prescribed by a Plan Physician, as Medically Necessary and provided in accord with this EOC. Including repairs and replacements, of such prosthetic devices.","EHB",null,null,"A wig prescribed by an oncologist for a Member suffering hair loss as a result of chemotherapy or radiation therapy is covered without Pre-Authorization up to one wig per year.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).","EHB",null,null,null,"EHB",null,null,"Must be medically necessary.","EHB",null,null,"Benefits are limited to the amount normally available for a basic (standard) appliance which allows necessary function. Basic (standard) medical devices or appliances are those that provide the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits include the purchase, fitting, adjustments, repairs and replacements.","EHB",null,null,"$5,000.00 lifetime limit for benefits related to the temporomandibular/craniomandibular joint (includes prosthetic appliances).  ","EHB",null,null,null,"EHB",null,null,"Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.","EHB",null,null,"Prior Approval is required. Benefits are available for externally worn breast prostheses and surgical bras, including necessary replacements following mastectomy, subject to a Maximum Benefit Allowance of 2 external prostheses and 2 bras per Member per Benefit Period. For a double mastectomy, allow a Maximum Benefit Allowance of 4 external prostheses and 2 bras per Member per Benefit Period.  ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",1,"Item(s) per 3 Years","Purchases are limited to a single purchase of a type of Prosthetic Device, including repair and replacement, every three (3) years. ","EHB",null,null,null,"EHB",null,null,"Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Medically necessary foot orthotics are not subject to a calendar year maximum. ",null,null,null,"Refer to section 31A-22-638. ","EHB",null,null,"Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women's Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period).","EHB",null,null,"The purchase, fitting, necessary adjustments, repairs, and replacements of prosthetics is covered, including prosthetic devices that are attached to (or inserted into) prosthetic shoes, and prosthetics which otherwise replace a missing body part.","EHB",null,null,null,"EHB",2500,"Dollars per Year",null,"EHB",null,null,null,"EHB",null,null,"Some items require Pre-Certification.  ","EHB",null,null,"The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns.  External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year and $150 maximum. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.","EHB"]
["Infusion Therapy","EHB",null,null,null,"EHB",null,null,"Covered under the Home Health benefit.","EHB",null,null,"Home infusion therapy.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Insulin infusion devices.","EHB",null,null,null,"EHB",null,null,"Intravenous administration of nutrients, antibiotics, and other drugs and fluids when provided in the home (home infusion therapy).","EHB",null,null,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.","EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.","EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"The preparation, administration, or furnishing of parenteral medications, or parenteral or enteral nutritional services to a Member by a Home Infusion Therapy Agency.","EHB",null,null,null,"EHB",null,null,"Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Subject to Horizon BCBSNJ Pre-Approval, the administration of antibiotic, nutrients, or other therapeutic agents by direct infusion.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Any visits for home infusion therapy count towards Your home health care visit limit.","EHB",null,null,"Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.","EHB",25,"Visit(s) per Benefit Period","Covered under Outpatient Therapy Services.","EHB",null,null,null,"EHB",null,null,"Infusion therapy includes all professional services, supplies, and equipment that are required to safely and effectively administer the therapy.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Infusion therapy is covered when provided in the home (home infusion therapy).","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Includes nursing, durable medical equipment and drug services that are delivered and administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections (intra-muscular, subcutaneous, continuous subcutaneous). Also covers prescription drugs when they are administered to you as part of a doctor's visit, home care visit, or at an outpatient Facility. ","EHB",null,null,null,"EHB",null,null,"Covered under applicable benefit (such as office visit).","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).","EHB"]
["Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,"The health plan cannot exclude coverage for surgical procedures for temporomandibular joint disorders (TMD or TMJ) under Health and Safety Code section 1367.68 if the service is a medically-necessary basic health care service.  Therefore, the Benchmark plan covers these services and they should be considered an EHB. ","EHB",null,null,"TMJ is listed in exclusions but the following Services for TMJ may be covered if a Plan Physician determines they are Medically Necessary: diagnostic X-rays; lab testing; physical therapy; and surgery.","EHB",null,null,"Some PT and surgery covered.",null,null,null,"Treatment is covered if there is documented organic joint disease, or joint damage resulting from physical trauma.","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Examination, radiographs and applicable imaging studies and consultation.",null,null,null,null,"EHB",null,null,null,"EHB",null,null,"Pediatric Dental Services covers temporomandibular joint syndrome (TMJ) treatment and treatment for craniomandibular pain syndrome (CPS). For adult members, only cover surgical services for TMJ and CPS, if Medically Necessary and if there is a clearly demonstrable radiographic evidence of joint abnormality due to disease or injury.",null,null,null,null,"EHB",null,null,"Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy,  and arthrocentesis.","EHB",null,null,"Only covers procedures that are Medically Necessary. Dental services that are not required to directly treat temporomandibular disorder are not covered.","EHB",null,null,"Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.","EHB",5000,"Dollars per Lifetime","Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required.",null,null,null,"Surgical treatment is covered as any other surgery. ","EHB",null,null,"Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.","EHB",2,"Treatment(s) per Lifetime","Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period.","EHB",null,null,null,"EHB",null,null,"Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.","EHB",null,null,"Horizon BCBSNJ covers charges for the Medically Necessary and Appropriate surgical and non-surgical treatment of TMJ in a Covered Person.","EHB",null,null,null,"EHB",null,null,"Covered if medically necessary.","EHB",null,null,"Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.","EHB",null,null,"Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.",null,null,null,null,"EHB",null,null,"Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.  Dental benchmark plan covers occlusal orthotic devices for temporomandibular pain, dysfunction or associated musculature.","EHB",null,null,"Diagnosis and Medically Necessary treatment of musculoskeletal disorders that affect any bone or joint in the face, neck, or head and are the result of accident, trauma, congenital defect, developmental defect, or pathology is covered to the extent required by 8 V.S.A. section 4089g.","EHB",null,null,null,"EHB",1250,"Dollars per Year",null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident;  2. Trauma;  3. A congenital defect; 4. A developmental defect; or 5. A pathology.","EHB"]
["Nutritional Counseling","EHB",null,null,null,null,null,null,null,"EHB",null,null,"When provided in conjunction with Diabetic Self-Management Training, for services needed by Members in connection with cleft palate management and for nutritional assessment programs provided in and by a Hospital and approved by Health Advantage.",null,null,null,null,"EHB",null,null,null,"EHB",2,"Visit(s) per Year","If needed carrier may develop explanations pertinent in defining the benefit attributes.","EHB",null,null,"Also covered per USPSTF guidelines.","EHB",null,null,"Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.'","EHB",4,"Visit(s) per Year",null,null,null,null,"Not covered except as identified on the U.S. Preventive Services Task Force list of Grade A and B Recommendations.",null,null,null,null,"EHB",3,"Visit(s) per Benefit Period","Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.",null,null,null,"This category signifies a benefit beyond that required under USPSTF AB Preventive Services. ","EHB",null,null,"Coverage is limited to nutritional education required for a disease in which patient self-management is an important component of treatment and there is a knowledge deficit regarding the disease which requires the intervention of a trained health professional; inborn errors of metabolism; or genetic conditions.","EHB",null,null,"Coverage only for diabetes education.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Cost share driven by provider/setting.","EHB",6,"Visit(s) per Year","Dietician Services.","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"Also covered under preventive health care. ","EHB",null,null,"Nutritional counseling visits are separate from the obesity-related office visits. ","EHB",4,"Visit(s) per Benefit Period","4 visits each per benefit period for hyperlipedemia, gestational diabetes, diabetes mellitus, and obesity; 2 visits per benefit period for hypertension.  ","EHB",null,null,"Only for diabetes management as provided by the plan.","EHB",null,null,null,"EHB",null,null,"Subject to Horizon BCBSNJ Pre-Approval, Horizon BCBSNJ covers charges for nutritional counseling for the management of disease entities which have a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Practitioner, and provided by a Practitioner.","EHB",null,null,"Covered: The following are covered benefits: Nutritional supplements for prenatal care when prescribed by a practitioner/provider are covered for pregnant women.; Nutritional counseling as medically necessary; Nutritional supplements that require a prescription to be dispensed are covered when prescribed by a Practitioner/Provider and when medically necessary to replace a specific documented deficiency.; Nutritional supplements administered by injection at the practitioner's/provider's office are covered when medically necessary.; Enteral formulas or products, as nutritional support, are covered only when prescribed by a practitioner/provider and administered by enteral tube feedings.; Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is covered when ordered by a practitioner/provider.; Special medical foods as listed as covered benefits in the Genetic Inborn Errors of Metabolism (IEM) benefit or as medically necessary.; Not Covered: The following are not covered: Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings.; Nutritional supplements prescribed by an attending practitioner/provider not due to a deficiency or as the sole source of nutrition.","EHB",1,"Visit(s) per Episode","Only covered in relation to diabetes management OR for an individual receiving home service (only 1 nutrition consultation covered for individual receiving home health services).",null,null,null,null,"EHB",null,null,"Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).","EHB",null,null,"Diabetes self-management training and training related to medical nutrition therapy.","EHB",5,"Visit(s) per Lifetime",null,"EHB",6,"Visit(s) per Benefit Period","Counseling visits or session need to be performed and billed by any of the following Providers, in an office setting: Member's Physician, Referred Specialist, or Registered Dietitian.","EHB",null,null,null,"EHB",null,null,null,null,null,null,null,"EHB",null,null,"For Diabetes Treatment only.",null,null,null,"Certain weight loss services such as nutritional and diet counseling are available through a diabetes management plan, autism benefits, and for adults at higher risk of chronic disease. ",null,null,null,"Not considered a separate benefit.  Should be considered under the benefits outlined for diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act Preventive Services. ","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,null,null,null,"Medical nutritional education services that are provided by appropriately licensed or registered health care professionals are covered when both of the following are true: Nutritional education is required for a disease in which patient self-management is an important component of treatment. There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.","EHB",null,null,"Diet education covered in the context of diabetes self-management education.",null,null,null,null,"EHB",null,null,"Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia","EHB",null,null,"Benefits available when provided in conjunction with preventive services, diabetic education, and hospice care."]
["Reconstructive Surgery","EHB",null,null,"Breast reconstruction allowed.","EHB",null,null,"Requires member and doctor to prove surgery is reconstructive, not cosmetic by providing medical and photographic evidence prior to and after surgery.","EHB",null,null,"1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is Prior Approved by Health Advantage is covered.","EHB",null,null,"Reconstructive surgery is covered to reconstruct a breast after it is fully or partially removed. Reconstructive surgery is also covered if the physician determines it is medically necessary improve the function or create a normal appearance of an abnormal structure.","EHB",null,null,"Reconstructive surgery is covered when a Plan Physician determines it: (a) will correct significant disfigurement resulting from an injury or Medically Necessary surgery; or (b) will correct a congenital defect, disease or anomaly to produce major improvement in physical function; or (c) will treat congenital hemangioma (port wine stains) on the face and neck of Members 18 years and younger. Following Medically Necessary removal of all or part of a breast, we also cover reconstruction of the breast, surgery and reconstruction of the other breast to produce a symmetrical appearance, and treatment of physical complications, including lymphedemas.","EHB",null,null,null,"EHB",null,null,"Only for breast reconstruction.","EHB",null,null,"Only for Breast reconstruction following a Mastectomy.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Only includes benefits for mastectomy-related services.","EHB",null,null,"Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed.  Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.","EHB",null,null,"Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term 'cosmetic' means procedures and related services performed to reshape structures of the body in order to alter the individual's appearance.","EHB",null,null,"Reconstructive procedures when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly.","EHB",null,null,"Breast Reconstructive Surgery Services.","EHB",null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.","EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,null,"EHB",null,null,"Benefits 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.","EHB",null,null,"Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.","EHB",null,null,"Reconstructive breast surgery only. Also covered in case of an accident/ injury or due to treat congenital anomaly. ","EHB",null,null,"Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. ","EHB",null,null,"Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes.","EHB",null,null,"Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.","EHB",null,null,null,"EHB",null,null,"Horizon BCBSNJ covers reconstructive breast Surgery, Surgery to restore and achieve symmetry between the two breasts and the cost of prostheses following a mastectomy on one breast or both breasts.","EHB",null,null,null,"EHB",null,null,"Coverage limited to Mastectomy Reconstructive Surgical Services.","EHB",null,null,null,"EHB",null,null,"Benefits 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. Benefits include surgery performed to restore symmetry after a mastectomy. ","EHB",null,null,"Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.","EHB",null,null,"Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. ","EHB",null,null,"The Health Benefit Plan will provide coverage for the following when performed after a mastectomy: Surgery to reestablish symmetry or alleviate functional impairment, including, but not limited to: Augmentation;  Mammoplasty;  Reduction mammoplasty; and Mastopexy.","EHB",null,null,null,"EHB",null,null,"Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy.","EHB",null,null,null,"EHB",null,null,"Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy).","EHB",null,null,"Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.","EHB",null,null,"Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.","EHB",null,null,"Includes 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. Also includes surgery performed to restore symmetry after a mastectomy. Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service. Hospital admissions for covered radical or modified radical mastectomy for the treatment of breast cancer shall be approved for a period of no less than 48 hours. Hospital admissions for a covered total or partial mastectomy with lymph node dissection for the treatment of breast cancer shall be approved for a period of no less than 24 hours.","EHB",null,null,"Reconstructive Procedures are covered when Medically Necessary unless expressly excluded. For purposes of this EHB Benchmark, \"Reconstructive Procedures \" are Medically Necessary procedures to correct gross deformities with physiological and functional impairments attributable to congenital defects, injury (including injuries occurring at birth), disease, or other health conditions (including gender dysphoria). \"Reconstructive Procedures \" include reconstruction of the breast, surgery and reconstruction of the other breast to produce a symmetrical appearance, and treatment of physical complications, including lymphedemas, following Medically Necessary removal of all or part of a breast or breasts.","EHB",null,null,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. ","EHB",null,null,null,"EHB",null,null,"(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.","EHB",null,null,"Pre-Certification Required. Reconstructive procedures which correct deformities of the jaw. Reconstructive Surgery is a Covered Service only where Participant's Surgery is required as the result of a birth defect, accidental injury, or a malignant disease process or its treatment.","EHB",null,null,"Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed;2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.","EHB",null,null,"Surgical procedures must be medically necessary, as determined by CareFirst, and must be operative procedures performed on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, or previous therapeutic intervention."]
["Gender Affirming Care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Medically-necessary gender-affirming care coverage",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"EHB",null,null,"Medically Necessary treatment for gender dysphoria and related health conditions is covered to the extent required by 8 V.S.A. section 4724 and Insurance Bulletin 174."]

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["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",null,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*",null,null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*",null,null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*",null,null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness"]
["Specialist Visit"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"]
["Outpatient Surgery Physician/Surgical Services"]
["Hospice Services"]
["Routine Dental Services (Adult)"]
["Infertility Treatment"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)"]
["Urgent Care Centers or Facilities"]
["Home Health Care Services"]
["Emergency Room Services"]
["Emergency Transportation/Ambulance"]
["Inpatient Hospital Services (e.g., Hospital Stay)"]
["Inpatient Physician and Surgical Services"]
["Bariatric Surgery"]
["Cosmetic Surgery"]
["Skilled Nursing Facility"]
["Prenatal and Postnatal Care"]
["Delivery and All Inpatient Services for Maternity Care"]
["Mental/Behavioral Health Outpatient Services"]
["Mental/Behavioral Health Inpatient Services"]
["Substance Abuse Disorder Outpatient Services"]
["Substance Abuse Disorder Inpatient Services"]
["Generic Drugs"]
["Preferred Brand Drugs"]
["Non-Preferred Brand Drugs"]
["Specialty Drugs"]
["Outpatient Rehabilitation Services"]
["Habilitation Services"]
["Chiropractic Care"]
["Durable Medical Equipment"]
["Hearing Aids"]
["Imaging (CT/PET Scans, MRIs)"]
["Preventive Care/Screening/Immunization"]
["Routine Foot Care"]
["Acupuncture"]
["Weight Loss Programs"]
["Routine Eye Exam for Children"]
["Eye Glasses for Children"]
["Dental Check-Up for Children"]
["Rehabilitative Speech Therapy"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy"]
["Well Baby Visits and Care"]
["Laboratory Outpatient and Professional Services"]
["X-rays and Diagnostic Imaging"]
["Basic Dental Care – Child"]
["Orthodontia – Child"]
["Major Dental Care – Child"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited"]
["Transplant"]
["Accidental Dental"]
["Dialysis"]
["Allergy Testing"]
["Chemotherapy"]
["Radiation"]
["Diabetes Education"]
["Prosthetic Devices"]
["Infusion Therapy"]
["Treatment for Temporomandibular Joint Disorders"]
["Nutritional Counseling"]
["Reconstructive Surgery"]
["Gender Affirming Care"]

{"sheet":"CSR","index":2,"n_rows":3,"n_cols":113,"rows_kept":3,"cut":false,"hidden":false,"merged":[[0,82,0,85],[0,105,0,112],[1,105,1,106],[1,107,1,108],[1,109,1,110],[1,111,1,112],[0,33,0,40],[0,41,0,48],[0,89,0,96],[1,89,1,90],[0,97,0,104],[1,97,1,98],[1,99,1,100],[1,91,1,92],[1,93,1,94],[1,95,1,96],[1,101,1,102],[1,103,1,104],[1,43,1,44],[1,79,1,81],[1,87,1,88],[0,79,0,81],[1,31,1,32],[0,13,0,24],[1,21,1,24],[0,69,0,78],[1,75,1,76],[1,77,1,78],[1,69,1,71],[1,72,1,74],[0,49,0,58],[1,59,1,61],[1,62,1,64],[0,59,0,68],[1,55,1,56],[0,25,0,32],[1,49,1,51],[1,52,1,54],[1,67,1,68],[1,57,1,58],[1,65,1,66],[1,0,1,12],[1,25,1,26],[1,39,1,40],[1,41,1,42],[1,47,1,48],[1,45,1,46],[1,17,1,20],[1,13,1,16],[1,27,1,28],[1,37,1,38],[1,33,1,34],[1,35,1,36],[1,29,1,30]]}
["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3"]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family"]

{"sheet":"Names","index":3,"n_rows":136,"n_cols":4,"rows_kept":136,"cut":false,"hidden":false,"merged":[]}
["Individual","AK",null,"Clinical Trials"]
["SHOP (Small Group)","AL",null,"Diabetes Care Management"]
[null,"AR",null,"Inherited Metabolic Disorder - PKU"]
["Bronze","AZ",null,"Newborn Hearing Screening"]
["Expanded Bronze","CA",null,"Off Label Prescription Drugs"]
["Silver","CO",null,"Dental Anesthesia"]
["Gold","CT",null,"Gastric Electrical Stimulation"]
["Platinum","DC",null,"Mental Health Other"]
["Catastrophic","DE",null,"Well Child Care"]
[null,"FL",null,"Prescription Drugs Other"]
["Yes","GA",null,"Coverage for Effects of Diethylstilbestrol"]
["No","HI",null,"Organ Transplants"]
[null,"IA",null,"Second Opinion"]
["Indemnity","ID",null,"Congenital Anomaly, including Cleft Lip/Palate"]
["PPO","IL",null,"Early Intervention Services"]
["HMO","IN",null,"Rehabilitative Occupational Therapy"]
["POS","KS",null,"Rehabilitative Physical Therapy"]
["EPO","KY",null,"Accidental Ingestion of a Controlled Drug"]
[null,"LA",null,"Bone Marrow Testing"]
["Allows Adult and Child-Only","MA",null,"Bones/Joints"]
["Allows Adult-Only","MD",null,"Developmental Needs of Children & Youth with Cancer"]
["Allows Child-Only","ME",null,"Mental Health Parity"]
[null,"MI",null,"Network Retail Pharmacy (60-90 Day Supply) Covered"]
["New","MN",null,"Post-Mastectomy Care"]
["Existing","MO",null,"Wound Care for Individuals with Epidermolysis Bullosa"]
[null,"MS",null,"Treatment of Medical Complications of Alcoholism"]
["Yes","MT",null,"Bone Marrow Transplant"]
["No","NC",null,"Nutrition/Formulas"]
["Not Applicable","ND",null,"Osteoporosis"]
[null,"NE",null,"Heart Transplant"]
["$X","NH",null,"Morbid Obesity Treatment"]
["Not Applicable","NJ",null,"Autism Spectrum Disorders"]
[null,"NM",null,"Breast Implant Removal"]
[null,"NV",null,"Multiple Sclerosis "]
["On Exchange","NY",null,"Applied Behavior Analysis Based Therapies"]
["Off Exchange","OH",null,"Cochlear Implants"]
["Both","OK",null,"Attention Deficit Disorder"]
[null,"OR",null,"Bone Marrow Transplants for Treatment of Breast Cancer"]
["Covered","PA",null,"Cardiac Rehabilitation"]
["Not Covered","RI",null,"Contraceptive Services"]
[null,"SC",null,"Hormone Replacement Therapy (HRT)"]
["Standard Plan","SD",null,"Human Leukocyte Antigen Testing"]
["73% AV CSR Silver Plan Variation","TN",null,"Hypodermic Syringes or Needles "]
["87% AV CSR Silver Plan Variation","TX",null,"Blood and Blood Services"]
["94% AV CSR Silver Plan Variation","UT",null,"Anesthetics"]
["Zero Cost Sharing Plan Variation","VA",null,"Treatment of Lyme Disease"]
["Limited Cost Sharing Plan Variation","VT",null,"Family Therapy"]
[null,"WA",null,"Oral Surgery"]
["Click here to select","WI",null,"Oxygen"]
[null,"WV",null,"Port-Wine Stain Removal"]
["Not EHB","WY",null,"Residential Treatment for Children with Emotional Disabilities"]
["Substituted",null,null,"Second Opinions Related to Chemical Dependency and Mental Health"]
["Substantially Equal",null,null,"Second Surgical Opinion"]
["Using Alternate Benchmark",null,null,"Services to Ventilator-Dependent Persons"]
["Other Law/Regulation",null,null,"Newborn Services Other"]
["Additional EHB Benefit",null,null,"Cancer Treatments"]
["Dental Only Plan Available",null,null,"Domestic Violence Treatment"]
[null,null,null,"Infant Formulas"]
["No Charge",null,null,"Sickle Cell Anemia"]
["No Charge after deductible",null,null,"Third Opinion"]
["$X",null,null,"Treatment of Hemophilia"]
["$X Copay after deductible",null,null,"Wilm's Tumor"]
["$X Copay with deductible",null,null,"Breast Reconstructive Surgery"]
[null,null,null,"Drug Infusion Administration"]
["$X Copay per Stay",null,null,"Eating Disorder Treatment"]
["$X Copay per Stay with deductible",null,null,"Experimental or Investigational Services"]
["$X Copay per Stay after deductible",null,null,"Brain Injury"]
["$X Copay per Day",null,null,"Transplant Surgery—Donor Charges"]
["$X Copay per Day with deductible",null,null,"Wigs"]
["$X Copay per Day after deductible",null,null,"Pediatric Services Other"]
["No Charge",null,null,"Transplant Donor Coverage"]
["No Charge after deductible",null,null,"Rape and Incest Coverage"]
["Not Applicable",null,null,"Outpatient Contraceptive Services Including Sterilizations"]
[]
["No Charge",null,null,"Click to enter Family MOOP"]
["No Charge after deductible"]
["X%",null,null,"Click to enter Family Deductible"]
["X% Coinsurance after deductible"]
[]
["Asthma"]
["Heart Disease"]
["Depression"]
["Diabetes"]
["High Blood Pressure & High Cholesterol"]
["Low Back Pain"]
["Pain Management"]
["Pregnancy"]
["Weight Loss Programs"]
[]
["Visit(s)"]
["Dollars"]
["Exam(s)"]
["Days"]
["Item(s)"]
["Months"]
["Treatment(s)"]
["Procedure(s)"]
["Hours"]
["Admission(s)"]
[]
["Year"]
["Benefit Period"]
["Lifetime"]
["Month"]
["Episode"]
["Stay"]
["Transplant"]
["6 Months"]
["2 Years"]
["3 Years"]
["Procedure"]
["Week"]
["Admission"]
[]
["Guaranteed Rate "]
[]
[]
["$X Copay per Stay"]
["$X Copay per Stay with deductible"]
["$X Copay per Stay after deductible"]
["$X Copay per Day"]
["$X Copay per Day with deductible"]
["$X Copay per Day after deductible"]
["No Charge"]
["No Charge after deductible"]
["Not applicable"]
["$X"]
["$X Copay after deductible"]
["$X Copay with deductible"]
[]
["Not Applicable"]
["Design 1"]
["Design 2"]
["Design 3"]
["Design 4"]
["Design 5"]