AultCare Platinum 300 - 28162OH0090050 Health Insurance Plan

Limit: 3000.0 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.

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

Limit: 12.0 Treatment(s) per Year

Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.

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.

Limit: 2.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

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.

Benefits include supportive use of an artificial kidney machine.

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.

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.

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Preventive Maintenance Tier 1 drugs are covered up to a 60-day supply with no cost share, including over-the-counter drugs, stop smoking aids, and nutritional or dietary supplements required by Preventive/Screening/Immunization benefits. Generic Tier 2 drugs are covered for a 34-day supply with a $10 Copayment or 20% Coinsurance, whichever is greater, or up to a 60-day supply with a $30 Copayment or 20% Coinsurance, whichever is greater. Non-Preferred Generic Tier 3 drugs are covered with $20 Copayment or 30% Coinsurance, whichever is greater. Non-Preferred Generic Tier 4 drugs are covered with $45 Copayment or 40% Coinsurance, whichever is greater.

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.

Limit: 100.0 Visit(s) per Year

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.

To be eligible for Hospice benefits, the patient must have a limited life expectancy, as confirmed by the attending Physician.

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.

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.

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.

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.

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

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.

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.

Non-Preferred Brand Tier 4 drugs are covered with $45 Copayment or 40% Coinsurance, whichever is greater.

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).

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

Other Practitioner Visit benefits and member cost share apply to services in a telehealth setting.

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

Limit: 116.0 Visit(s) per Year

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 and Occupational Therapy limited to 40 visits combined. Speech Therapy limited to 20 visits. 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 Year maximum for both Inpatient and outpatient day rehabilitation therapy services.

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.

Preferred Brand Tier 3 drugs are covered with $20 Copayment or 30% Coinsurance, whichever is greater.

Cost sharing does not apply to certain preventive services. Depending on the type of service, a copayment, deductible, or coinsurance may apply. 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).

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.

Primary Care Visit benefits and member cost share apply to services in a telehealth setting. Primary Care Visit benefits and member cost share apply to Mental Health and Substance Abuse services in an office or telehealth setting.

Limit: 90.0 Visit(s) per Year

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.

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.

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.

Limit: 40.0 Visit(s) per Year

Physical and Occupational Therapy limited to 40 visits combined per benefit period.

Limit: 20.0 Visit(s) per Year

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Limit: 90.0 Days per Year

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.

Specialist Visit benefits and member cost share apply to services in a telehealth setting.

Exclusions: Specialty drugs exclude purchases through retail pharmacies. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy.

Preferred Generic Specialty Tier 5 drugs are covered with $10 Copayment or 20% Coinsurance, whichever is greater. Preferred Brand Specialty Tier 6 drugs are covered with $50 Copayment or 50% Coinsurance, whichever is greater. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy.

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.

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.

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 and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.

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.