Gold Classic Standard - 77739MI0070053 Health Insurance Plan

Exclusions: Skin titration (Rinkle Method), cytotoxicity testing (Bryan's Test), MAST testing, urine auto-injections, bronchial or oral allergen sensitization and provocative and neutralization testing for allergies.

Allergy testing, evaluations and injections, including serum costs.

Limit: 1.0 Procedure(s) per Lifetime

Physician-supervised weight loss programs as outlined in our medical policies. (b) Certain surgical treatments when comorbid health conditions exist and all reasonable non-surgical options have been tried. NOTE: Surgical treatment of obesity is limited to once per lifetime unless Medically/Clinically Necessary to correct or reverse complications from a previous bariatric procedure.

The following drugs are covered as medical benefits; Injectable and infusible drugs administered in an inpatient or emergency setting, injectable and infusible drugs requiring administration by a Health Professional in a medical office, home or outpatient facility.

Limit: 30.0 Visit(s) per Year

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services.

Covered Services(a) Hospital and Provider care. Services and supplies furnished by a Hospital or Provider for prenatal care, including genetic testing, postnatal care, Hospital delivery, and care for the Complications of Pregnancy. The mother and Newborn have the right to an inpatient stay of no less than 48 hours following a normal vaginal delivery or no less than 96 hours following a cesarean section. If the mother and her attending Physician agree, the mother and the Newborn may be discharged from the Hospital sooner. (b) Newborn child care. A Newborn child (including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities) for the first 31 days from birth. Telephone assessment and home visits by a registered nurse shortly after the date of the mother's discharge for evaluation of the mother, Newborn and family. These services are only available if your Provider identifies a medical need. (d) Maternity education programs

Diabetes educational classes to ensure that persons with diabetes are trained as to proper self-management and treatment of their diabetes.

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to- day activities that are significant in your life roles

DME is equipment intended for repeated use in order to serve a medical need, is generally not useful to a person in the absence of Illness or Injury, and is appropriate for use in the home. Examples of Covered DME are manual wheelchairs, CPAP machines and glucose monitoring devices.

Medical Emergency care and Urgent Care services are Covered.

Ambulance includes a motor vehicle or aircraft that is primarily used or designated as available to provide transportation and basic life support, limited advanced life support, or advanced life support. In a Medical Emergency, we will Cover EMT and ambulance service to the nearest medical facility that can provide Medical Emergency care. We will Cover ambulance transfers between facilities that we approve in advance.

Limit: 1.0 Item(s) per Year

Polycarbonate lenses are covered in full for children

Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered.

Limit: 30.0 Visit(s) per Year

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services.

Exclusions: Custodial Care is not Covered, even if you receive Covered Home Health Care or Skilled Nursing Services at the same time you receive Custodial Care.

Intermittent skilled services furnished in the home by a physical therapist, occupational therapist, respiratory therapist, speech therapist, licensed practical nurse or registered nurse. Home Health Care is Covered when you are: (a) confined to the home, (b) under the care of a Physician, (c) receiving services under a plan of care established and periodically reviewed by a Physician, and (d) in need of intermittent skilled nursing care or physical, speech, or occupational therapy.

Exclusions: Custodial Care is not Covered even if you receive inpatient or outpatient Hospice Care along with Custodial Care.

The following Hospice Care services, provided as part of an established hospice program are Covered when your Physician informs Priority Health that your condition is terminal and Hospice Care would be appropriate: (a) Inpatient Hospice Care. Short-term inpatient care in a licensed hospice facility is Covered when Skilled Nursing Services are required and cannot be provided in other settings. Prior Approval of inpatient Hospice Care is required. (b) Outpatient Hospice Care. Outpatient care is Covered when intermittent Skilled Nursing Services by a registered nurse or a licensed practical nurse are required or when medical social services under the direction of a Physician are required. Outpatient Hospice Care is any care provided in a setting other than a licensed hospice facility. Hospice Care provided while you are in a Hospital or skilled nursing facility is considered outpatient Hospice Care. (c) Respite Care. Respite care in a facility setting is Covered as outlined in our medical policies.

Diagnostic and therapeutic radiology services and laboratory tests. All non-emergency laboratory tests, including high-tech radiology examinations, must be performed at a participating laboratory or facility. Radiology services and laboratory tests performed in a Hospital, either while you are an inpatient or an outpatient.

Diagnostic, counseling, and planning services for treatment of the underlying cause of infertility. Examples of Covered Services are sperm count, endometrial biopsy, hysterosalpingography, and diagnostic laparoscopy

The following drugs are covered as medical benefits; Injectable and infusible drugs administered in an inpatient or emergency setting, injectable and infusible drugs requiring administration by a Health Professional in a medical office, home or outpatient facility.

(a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies.

(a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies.

This plan Covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions. Acute Inpatient Hospitalization.

This plan Covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions. Both crisis intervention and solution-focused treatment are Covered. 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.

Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered.

Limit: 6.0 Visit(s) per Year

Covered Services Consultations with a Participating dietitian, upon referral from your PCP, up to a maximum of 6 visits per Contract Year.

Your PCP may be a nurse practitioner or a physician assistant.

Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure.

Limit: 30.0 Visit(s) per Year

PT/OT/Chiro - combined visits per contract year; 30 ST per contract year; 30 cardiac/ pulmonary visits per contract year.

Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure.

Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered.

Covered Services(a) Hospital and Provider care. Services and supplies furnished by a Hospital or Provider for prenatal care, including genetic testing, postnatal care, Hospital delivery, and care for the Complications of Pregnancy. The mother and Newborn have the right to an inpatient stay of no less than 48 hours following a normal vaginal delivery or no less than 96 hours following a cesarean section. If the mother and her attending Physician agree, the mother and the Newborn may be discharged from the Hospital sooner. (b) Newborn child care. A Newborn child (including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities) for the first 31 days from birth. Telephone assessment and home visits by a registered nurse shortly after the date of the mother's discharge for evaluation of the mother, Newborn and family. These services are only available if your Provider identifies a medical need. (d) Maternity education programs

Covered preventive health care services include: (a) Immunizations (doses, recommended ages, and recommended populations vary), Certain vaccines-children from birth to age 18. Certain vaccines-all adults

Cost share applies to both in-person and telemedicine services. Your PCP provides your primary health care, orders lab tests and x-rays, prescribes medicines or therapies and arranges hospitalization when necessary. Your PCP may be a family practitioner, a general practitioner, an internal medicine specialist, a pediatrician, an obstetrician/gynecologist, a nurse practitioner or a physician assistant.You may choose to seek services from a Participating Provider without referral from your PCP at any time

Prosthetic and Orthotic/Support Devices. Covered Services Surgically implanted prosthetic devices, such as a replacement hip or heart pacemaker. Externally worn prosthetic devices. Purchased, repaired or replaced prosthetics and orthotics, repairs or replacement, fitting and adjustment of Covered prosthetic and orthotic/support devices that is need as the result of normal use, body growth or change.

Diagnostic and therapeutic radiology services and laboratory tests..

Reconstructive surgery to correct congenital birth defects and/or effects of Illness or Injury, if: The defects and/or effects of Illness or Injury cause clinical functional impairment. "Clinical functional impairment" exists when the defects and/or effects of Illness or Injury: causes significant Disability or major psychological trauma (psychological reasons do not represent a medical or surgical necessity unless you are undergoing psychotherapy for issues solely related to the Illness or Injury for which the reconstructive surgery is requested), interfere with employment or regular attendance at school, require surgery that is a component of a program of reconstructive surgery for a congenital deformity or trauma, or contribute to a major health problem.

Limit: 30.0 Visit(s) per Year

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services.

Limit: 30.0 Visit(s) per Year

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services.

Limit: 1.0 Exam(s) per Year

Vision Screening-all children

Limit: 45.0 Days per Year

Care and treatment, including therapy, and room and board in semi-private accommodations, at a skilled nursing, subacute, or inpatient rehabilitation facility is Covered when we have approved a treatment plan in advance.

Cost share applies to both in-person and telemedicine services. Referral care is care provided by a Health Professional or Physician other than your PCP. You may request a second medical opinion from a Participating Specialist Provider who has skills and training substantially similar to those of the Physician making the original treatment recommendation without Prior Approval. If there are no Participating Providers with the skills and training needed to provide a second opinion on the proposed treatment, we may Cover a second medical opinion from a Non-Participating Specialist Provider. Prior Approval from Priority Health is required before the second opinion is obtained. Any tests, procedures, treatments or surgeries recommended by the consulting Provider must be performed by a Participating Provider unless we approve the services in advance.

Prescription Drugs and Supplies, Drugs and supplies that are prescribed and received during a Covered inpatient stay are Covered as medical benefits.drugs for cancer therapy and the reasonable cost of administering them are Covered.

Substance abuse services, including counseling, medical testing, diagnostic evaluation and detoxification are Covered in a variety of settings. You may be treated in an inpatient or outpatient setting, depending on your particular condition.

Substance abuse services, including counseling, medical testing, diagnostic evaluation and detoxification are Covered in a variety of settings. You may be treated in an inpatient or outpatient setting, depending on your particular condition. 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.

Evaluations for transplants and transplants of the following organs, bone marrow or stem cell, cornea, heart, kidney, liver, lung, pancreas, and small bowel. In addition, we will cover the following expenses: computer organ bank searches and any subsequent testing necessary after a potential donor is identified, unless covered by another health plan, typing or screening of a potential donor only if the person proposed to receive the transplant is a member, donor's medical expenses directly related to or as a result of a donation surgery if the person receiving the transplant is a member and the donor's expenses are not covered by another health benefit plan, one comprehensive evaluation per transplant.

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.

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. Medical Emergency care and Urgent Care services are Covered under this Certificate.

Physician-supervised weight loss programs