Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated cesarean section.

Exclusions: Durable medical equipment not provided for Home Health Care. Rental covered under medical/surgical. Excluded from pharmacy benefits, but permitted for diabetes and self-administered injections. Female contraception and breast pumps covered under medical/surgical benefits.

Long-term supplemental oxygen is covered in full for members with COPD and other medical conditions that can be treated with long-term supportive oxygen therapy. Prior authorization for medical necessity may apply.

Preferred generic drugs, including common prescription generic statins, antiasthmatics, and bronchodilators (inhalers), are covered in full.

Limit: 35.0 Visit(s) per Year

Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage

To restore or correction of impaired speech or hearing loss.

Limit: 60.0 Visit(s) per Year

Exclusions: Benefits will not be provided for Home Health Care for Food or home delivered meals; Social case work or homemaker services; Services provided primarily for Custodial Care; Transportation services; Home Infusion Therapy; and Durable medical equipment.

Preauthorization is required.

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full.

Preauthorization is required.

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. Preauthorization is required.

Limit: 35.0 Visit(s) per Year

Cardiac and pulmonary rehab visits are covered in full. Limited to combined 35 visits per year, including Chiropractic.

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

Medically necessary foot orthotics are not subject to a calendar year maximum.

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

Limit: 25.0 Visit(s) per Year

Qualified specialist visits for cardiology, pulmonology, and endocrinology are covered in full. Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.

Preauthorization is required.

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. Certain services require preauthorization.

Preauthorization is required.

Exclusions: Excludes any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves.

Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.

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

Certain weight loss services such as nutritional and diet counseling are available through a diabetes management plan, autism benefits, and for adults at higher risk of chronic disease.