Gold Classic Standard - 43490KS0010053 Health Insurance Plan

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 and the associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions).

Allergy testing and treatment.

Also covers surrogate mother if there is a petition to adopt within 90 days of birth. See plan documents for separate professional services cost shares.

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.

Plan cover Hemodialysis.

Exclusions: Items for comfort or convenience are not covered. Included within the definition of convenience items are: (a) Pieces of equipment used to provide exercise to functioning and non-functioning portions of the body when leased, purchased, or rented for use outside a recognized institutional facility. (b) Those pieces of equipment designed to provide the walking capability for individuals with nonfunctioning leg

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.

Emergency transportation/ambulance within 500 mile radius.

Three (3) prescribed lenses and frames per Benefit Period. Contact lenses covered in lieu of glasses.

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.

Exclusions: Excludes services provided by a member of the Insured's immediate family; Provided by a person who normally lives in the Insured's home; or Which are Custodial/Maintenance care. The Company has the right to determine which services are Custodial/Maintenance care.

Includes educational visits with a limit of three per year on educational visits.

Exclusions: Blood

Exclusions: Diagnostic tests and evaluations are ordered, requested or performed solely for the purpose of resolving issues in the context of legal proceedings, including those concerning custody, visitation, termination of parental rights, civil damages or criminal actions.

Exclusions: Excludes In vitro fertilization, in vivo fertilization or any other medically-aided insemination procedure.

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.

Exclusions: Blood

Exclusions: Diagnostic tests and evaluations are ordered, requested or performed solely for the purpose of resolving issues in the context of legal proceedings, including those concerning custody, visitation, termination of parental rights, civil damages or criminal actions.

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Professional Providers include Physician Assistants. Registered Nurses qualify as Eligible Providers.

Limit: 90.0 Days per Benefit Period

Exclusions: Excludes vocational rehabilitation; Cognitive therapy; social rehabilitation.

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.

Also covers surrogate mother if there is a petition to adopt within 90 days of birth.

Cost share applies to both in-person and telemedicine services.

Exclusions: Excludes services provided by a member of the Insured's immediate family; Provided by a person who normally lives in the Insured's home; or Which are Custodial/Maintenance care. The Company has the right to determine which services are Custodial/Maintenance care.

Exclusions: (1) Benefits are not provided for eyeglasses and contact lenses. Exception: Benefits are available for the initial eyeglasses/contacts following surgery for cataracts, aphakia, or pseudophakia, or an Insured under 12 years of age is eligible for subsequent eyeglasses/contacts following cataract surgery when there is a minimum change of .25 diopter. (2) Benefits are not provided for hearing aids, hair prosthesis or dental appliances including plates, bridges, prostheses or braces. (3) Benefits are not provided for items of wearing apparel except coverage is available for two postmastectomy bras per Insured per Benefit Period. A post-mastectomy bra is a bra that is specifically designed and intended to support single or bilateral breast prostheses. (4) Benefits are limited to the allowable amount for a basic/standard appliance which provides the essential function(s) required for the treatment or amelioration of the medical condition. (5) Charges for deluxe or electrically operated appliances or devices are not covered beyond the allowable amount for basic/standard appliances. Deluxe describes medical devices or appliances that have enhancements that allow for additional convenience or use beyond that provided by a basic/standard device or appliance. (6) Benefits are not provided for custom or over-the-counter orthotic devices, appliances including shoe inserts.

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.

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.

Exclusions: Materials used for occupational therapy are excluded.

Limit: 90.0 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.

One (1) refraction visit per Benefit Period. Limit does not apply to all other medically necessary eye exams;

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.

Cost share applies to both in-person and telemedicine services.

Exclusions: Coverage for Specialty Prescription Drugs will be limited to a supply sufficient for 34 consecutive days of therapy.

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: There is no coverage hereunder for any transplant not specifically listed as covered or for supplies or services provided directly for or relative to human organ transplants not specifically listed as covered.

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.

Exclusions: Phase II irreversible treatment; equilibration of occlusion, coronoplasty, occlusal adjustment; slides and/or photographs; non-prescription drugs, vitamins, nutrition supplements; stretching and other exercises; coolant sprays; moist heat therapy; hot packs; massage, either manual or by machine; acupuncture; cold packs; range of motion treatments; diet survey; nutrition counseling; rental or purchase of transcutaneous electrical nerve stimulators; office visits; periapical, bitewing and full-mouth radiographs; orthodontic treatment, including both fixed and removable appliances used for the purpose of moving teeth.

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.

Exclusions: Diagnostic tests and evaluations are ordered, requested or performed solely for the purpose of resolving issues in the context of legal proceedings, including those concerning custody, visitation, termination of parental rights, civil damages or criminal actions.