Schedule of Benefits-EPO [Plan Information] [Health Plan:] [Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan] [Primary Member:] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62] [Effective Date:] [1/1/2018] [Last Coverage Change Date:] [1/1/2018] [Dependent Information] [First Name:] [Jane Doe] [Relationship to You:] [Spouse] [Birth Date:] [08/12/62] [Effective Date:] [1/1/2018] The Schedule of Benefits is a summary of services that may be covered under the plan. Benefits listed are subject to all provisions and limitations as outlined in the Evidence of Coverage (EOC). Please reference the EOC for details regarding the benefits listed below. The member is responsible for deductible, copayment or coinsurance applied to eligible service expenses. An overview of Preventive Services covered with no cost share can be found within your EOC. Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan Benefit Insured Responsibility(per person) In-Network Providers Out-of-Network Providers Annual Deductible per Calendar Year $3,000 Individual $6,000 Family Coinsurance For All Other Eligible Expenses 30% Coinsurance Not applicable Out-Of-Pocket Maximum per Calendar Year $6,500 Individual $13,000 Family Physician Office Services Primary Care Physician and Other Practitioner Office Visit $30 Copay Not applicable Individual Not applicable Family Not applicable Individual Not applicable Family Specialist Physician Office Visit* $60 Copay Preventive Care (including screenings, No charge immunizations and well-baby visits) Diagnostic Test (x-ray and lab-work)* Imaging Test (CT/PET scans, MRI)* Prescription Drugs Generic $25 Copay Preferred Brand* $50 Copay Non-Preferred Brand* Specialty* Mail Order (90 day supply) 3 Times Retail Cost Sharing Outpatient Services Outpatient Facility* Outpatient Surgery Physician/Surgical Services*
Laboratory Outpatient and Professional Services Emergency and Urgent Care Services Emergency Room $600 Copay before deductible $600 Copay before deductible Emergency Transportation/Ambulance (Air* 30% Coinsurance after deductible 30% Coinsurance after deductible Water* or Ground) Urgent Care $100 Copay Inpatient Hospital Services Inpatient Hospital Facility* $750 Copay per day before deductible Inpatient Hospital Physician and Surgical Services* Mental Health and Substance Abuse Disorder Services, including Behavioral Health Treatment Mental/Behavioral Health Outpatient Services* (PCP and Other Practitioner visits do not require Prior Authorization) $30 Copay for office visits; 30% Coinsurance after deductible for all other outpatient services Mental/Behavioral Health Inpatient Services* $750 Copay per day before deductible Substance Abuse Disorder Outpatient Services* (PCP and Other Practitioner visits do not require Prior Authorization) $30 Copay for office visits; 30% Coinsurance after deductible for all other outpatient services Substance Abuse Disorder Inpatient Services* $750 Copay per day before deductible Maternity and Newborn Care Prenatal and Postnatal Care* $30 Copay Delivery and Inpatient Services* $750 Copay per day before deductible Other Covered Services Home Health Care Services* 100 visits per year Rehabilitation Outpatient Services (Including Occupational and Physical Therapy)* 20 visits per therapy per year. PT and OT (Limits do not apply to Speech Therapy) Rehabilitative Speech Therapy* (Inpatient and Outpatient) Habilitation Services* 20 visits per benefit period. (Limits do not apply to Autism Services) Skilled Nursing Facility and Inpatient Rehabilitation Services* 150 days per year combined Durable Medical Equipment* Hospice Services* Respite Services (Inpatient/Outpatient) 5 visits per 90 days Private Duty Nursing* 82 visits per year Chiropractic Care* Up to 26 visits per year;visits in excess of 26 require prior authorization $60 Copay Transplant Benefit* $750 Copay per day before deductible Diabetes Care Management* $60 Copay Hearing Aids* 1 pair per year Temporomandibular Joint Disorder* Vision Services Pediatric (Up to 19 years of age) Exams and Eyewear $0 Copay Routine Eye Exam 1 Visit per year Eyeglasses (frames) and contacts 1 Item per year 100% Covered 100% Covered Lenses (per pair) Single 100% Covered
Bifocal 100% Covered Trifocal 100% Covered Lenticular 100% Covered Contact Lenses Contact lenses (in lieu of 100% Covered glasses) Contact Lens Fitting 100% Covered Specialty Lens Fitting 100% Covered Wellness Programs; Disease or Case Management Programs; Other Programs $25 to $250 The benefit available for participation in a wellness program, a disease or case management program or another program will usually be in the form of a credit added to a debit card we issue to the member and, depending on the particular program, is usually between $25 and $250. Such credits may be one-time rewards, available periodically or related to specific requirements under a particular program. Discounts also may be available for participating in a program. You may obtain information regarding the available programs, the requirements for participation in each program and the benefits available for participating in a particular program in your EOC, by visiting our website at Ambetter.HomeStateHealth.com or by contacting Member Services by telephone at 1-855-650-3789 (TTY/TDD 1-877-250-6113).