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Standard Silver Benefits
  PCY = per calendar year   LifeWise providers
  Plan Type Describes how you can use your plan PPO
  Schedule of Benefits Benefits, exclusions and definitions Click here to view
  Provider network LifeWise Provider Search
Rx Search
  Annual Deductible PCY (choose one)
Family = 2x individual (In-network only)
  Coinsurance Amount you pay after your deductible is met 30%
  Out-of-pocket maximum Includes deductible, coinsurance & copays
Family = 2x individual (In-network only)
  Office Visits Designated PCP office visit
Non-designated PCP or specialist office visit
$35 copay
$70 copay
  10 Essential Benefits Covered Services  
1 Ambulatory Patient Services Outpatient Deductible, then 30%
2 Emergency Services Emergency Room Deductible, then 30%
Urgent care Deductible, then 30%
Ambulance Deductible, then 30%
3 Hospitalization Inpatient Deductible, then 30%
Organ and tissue transplants, 2 roundtrip tickets and 2 weeks lodging per transplant Deductible, then 30%
Hospice: unlimited. Respite care: 5 consecutive days; 30 days lifetime max Deductible, then 30%
4 Maternity & Newborn Care Routine prenatal care visit, first postpartum visit
Deductible, then 30%
Delivery and inpatient well-baby care Deductible, then 30%
5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Office visit $70 copay
Inpatient hospital: mental/behavioral health Deductible, then 30%
Outpatient services Deductible, then 30%
6 Prescription Drugs Tier 1 (generic) $15 copay
Tier 2 (preferred brand) $50 copay
Tier 3 (non-preferred brand) Waive deductible, then 50%
Tier 4 (specialty) Waive deductible, then 50%
7 Rehabilitative & Habilitative Services & Devices Therapy Inpatient rehabilitation: 30 days PCY Deductible, then 30%
Physical, speech, occupational, massage therapy: 30-60 visits PCY $35 copay
Durable medical equipment Deductible, then 30%
Skilled nursing facility: 60 days PCY Deductible, then 30%
8 Laboratory Services Most X-ray and lab tests Deductible, then 30%
MRI, CT, PET Deductible, then 30%
9 Preventive/Wellness Services & Chronic Disease Management Screenings
Covered in full
Exams and immunizations Covered in full
10 Pediatric Services (Vision Care)
Under 19 years of age
Eye exam: 1 PCY $35 copay
Eyewear: 1 set frames/lenses or 1 set contacts every 2 years Deductible, then 30%

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.

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