Silver Standardized - 75293AR1200026 Health Insurance Plan

SOB includes 'allergy services.'

Limit: 30.0 Visit(s) per Year

Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.

One cochlear implant per ear per Covered Person per lifetime

Childbirth/delivery professional services: 75293AR1200026-01-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-02-No charge for in-network and out-of-network services; 75293AR1200026-03-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-04-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-05-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-06-25% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company.

Limit: 1.0 Item(s) per Year

Mail Order cost: 75293AR1200026-01- $40 Copay in-network, 75293AR1200026-03- $40 Copay in-network, 75293AR1200026-04- $40 Copay in-network, and 75293AR1200026-05- $20 Copay in-network

Limit: 30.0 Visit(s) per Year

Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year.

Coverage is limited to $1400/ear

Limit: 50.0 Visit(s) per Year

Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.).

If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits.

4 oocyte retrievals or 2 live births from separate pregnancies

Home infusion therapy.

Cost Sharing does NOT apply to screenings.

Mail Order cost: 75293AR1200026-01- $160 Copay after deductible in-network, 75293AR1200026-03- $160 Copay after deductible in-network, 75293AR1200026-04- $160 Copay after deductible in-network, 75293AR1200026-05- $120 Copay after deductible in-network, and 75293AR1200026-06- $100 Copay in-network.

Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by the company.

Limit: 30.0 Visit(s) per Year

Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.

Mail Order cost: 75293AR1200026-01- $80 Copay in-network, 75293AR1200026-03- $80 Copay in-network, 75293AR1200026-04- $80 Copay in-network, 75293AR1200026-05- $40 Copay in-network, and 75293AR1200026-06- $30 Copay in-network.

Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1.

Limit: 1.0 Visit(s) per Year

Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device's useful life.

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is covered.

Limit: 30.0 Visit(s) per Year

Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.

Limit: 30.0 Visit(s) per Year

Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro.

Limit: 1.0 Visit(s) per 2 Years

Limit: 1.0 Exam(s) per Year

Limit: 60.0 Days per Year

1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function.

Requires Prior Approval from the Company.

Requires Prior Approval from the Company.