Market HMO 4000 HSA - 99969OH0080494 Health Insurance Plan

Limit: 12.0 Visit(s) per Benefit Period

Limit: 2.0 Exam(s) per Benefit Period

Cochlear implants are covered. 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.

Limit: 1.0 Item(s) per Year

Tier 1 Generics include only the drugs listed in Tier 1A Generic Standard Plus Preventive on the ACA Advantage Formulary. Tier 2 Generics are all other generic medications listed on the ACA Advantage Formulary under Tier 1B. Generic drugs are copies of brand-name drugs that contain the same active ingredients but are usually less expensive. They also must meet the same strict U.S. Food and Drug Administration (FDA) standards for quality, strength and purity. If you fill a Generic drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

This includes coverage for those with a medical diagnosis of Autism Spectrum disorder. These limits apply: 20 visits per year for Speech Therapy; 20 visits per year for Occupational Therapy; and 20 visits per year for Physical Therapy.

Limit: 100.0 Visit(s) per Benefit Period

Only diagnostic and exploratory procedures required to diagnose infertility and certain surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs are covered.

Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

One (1) Inpatient visit per day per Physican or other Professional Provider

Non-preferred Brand-name drugs, your third cost-share tier, are included in Medical Mutual?s formulary but are typically more expensive than similar Preferred Brand-name drugs. If you fill a Non-preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

Medically necessary only

20 visits for Speech Therapy, 20 visits for Pulmonary Rehabilitation and 36 visits for Cardiac Rehabilitation.? Benefit also includes Physical Medicine and Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

Preferred Brand-name drugs, your second cost-share tier, are included in Medical Mutual's formulary and are typically less expensive than similar Non-preferred Brand-name drugs. They are safe, effective alternatives to other brand-name drugs that may cost more. If you fill a Preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

Pap test - one per benefit period. Mammogram - one per benefit period.

On Demand Telemedicine: 0% after $0 Copay

Limit: 90.0 Days per Benefit Period

Limit: 40.0 Visit(s) per Benefit Period

20 visits for Rehabilitative Occupational Therapy and 20 visits for Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

Preventive services only.? See plan certificate for more information.

Limit: 90.0 Days per Benefit Period

Specialty drugs must be obtained through a contracted specialty pharmacy, and are limited to a 30-day supply.

Per Transplant: $30,000 maximum for unrelated donor search. $10,000 maximum for transportation, meals & lodging.