CMS-10433 Plans and Benefits Template

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Overview

Benefits Package
Cost Share Variances

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Sheet 1: Benefits Package

Plans & Benefits Template

To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required

Fields with a tilde "~" indicate a field that would be added for PY 2017 under this PRA package. Fields with a caret "^" indicates revisions that will be not be implemented for PY 2017 but will be included in PY 2018. Fields with a number sign (hash mark) "#" indicate a field that would be moved or removed under this PRA package.

You will need to save the latest version of the add-in file (PlansBenefitsAddIn.xlam) on your machine.

To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro.

To create additional Benefits Package worksheets, use the Create New Benefits Package macro.

To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro.

HIOS Issuer ID*

Issuer State*

Market Coverage*

Dental Only Plan*

TIN*

Multi-State Plan~

Benchmark Used~

Plan Identifiers - HIOS Plan ID* (Standard Component)

Plan Identifiers - Plan Marketing Name*

Plan Identifiers - HIOS Product ID*

Plan Identifiers - HPID

Plan Identifiers - Network ID*

Plan Identifiers - Service Area ID*

Plan Identifiers - Formulary ID*

Plan Attributes - New/Existing Plan?*

Plan Attributes - Plan Type*

Plan Attributes - Level of Coverage*

Plan Attributes - Unique Plan Design?*

Plan Attributes - QHP/Non-QHP*

Plan Attributes - Notice Required for Pregnancy*

Plan Attributes - Is a Referral Required for Specialist?*

Plan Attributes - Specialist(s) Requiring a Referral

Plan Attributes - Plan Level Exclusions

Plan Attributes - Limited Cost Sharing Plan Variation - Est Advanced Payment

Plan Attributes - Does this plan offer Composite Rating?*

Plan Attributes - Child-Only Offering*

Plan Attributes - Child Only Plan ID

Plan Attributes - Tobacco Wellness Program Offered*

Plan Attributes - Disease Management Programs Offered

Plan Attributes - EHB Percent of Total Premium*

Plan Attributes - Plan Design Type~

Stand Alone Dental Only - EHB Apportionment for Pediatric Dental

Stand Alone Dental Only - Guaranteed vs. Estimated Rate

AV Calculator Additional Benefit Design - Maximum Coinsurance for Specialty Drugs#

AV Calculator Additional Benefit Design - Maximum Number of Days for Charging an Inpatient Copay?#

AV Calculator Additional Benefit Design - Begin Primary Care Cost-Sharing After a Set Number of Visits?#

AV Calculator Additional Benefit Design - Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?#

Plan Dates - Plan Effective Date*

Plan Dates - Plan Expiration Date

Geographic Coverage - Out of Country Coverage*

Geographic Coverage - Out of Country Coverage Description

Geographic Coverage - Out of Service Area Coverage*

Geographic Coverage - Out of Service Area Coverage Description

Geographic Coverage - National Network*

Plan Level URLs - URL for Enrollment Payment

Benefits

Benefit Information - EHB

Benefit Information - EHB Category*~

Benefit Information - State-Required Benefit

Benefit Information - Is this Benefit Covered?

General Information - Quantitative Limit on Service

General Information - Limit Quantity

General Information - Limit Unit

General Information - Care Plan Limit?~^

General Information - Number of Visits before Care Plan Limit applies~^

General Information - Minimum Stay

General Information - Exclusions

General Information - Benefit Explanation

General Information - EHB Variance Reason

General Information - Excluded from In Network MOOP

Out of Pocket Exceptions - Excluded from Out of Network MOOP

Out of Pocket Exceptions - Excluded from Out of Network MOOP2

Primary Care Visit to Treat an Injury or Illness

Mental Health and Substance Abuse Disorder Office Visit~^

All Other Mental Health/Substance Use Outpatient Visits~^

Specialist Visit

Other Practitioner Office Visit (Nurse, Physician Assistant)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Hospice Services

Non-Emergency Care When Traveling Outside the U.S.

Routine Dental Services (Adult)

Infertility Treatment

Long-Term/Custodial Nursing Home Care

Private-Duty Nursing

Routine Eye Exam (Adult)

Urgent Care Centers or Facilities

Home Health Care Services

Emergency Room Services

Mental Health Emergency Services~

Emergency Transportation/Ambulance

Inpatient Hospital Services (e.g., Hospital Stay)

Inpatient Physician and Surgical Services

Bariatric Surgery

Cosmetic Surgery

Skilled Nursing Facility

Prenatal and Postnatal Care

Delivery and All Inpatient Services for Maternity Care

Mental/Behavioral Health Outpatient Services

Mental/Behavioral Health Inpatient Services

Substance Abuse Disorder Outpatient Services

Substance Abuse Disorder Inpatient Services

Generic Drugs

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs

Outpatient Rehabilitation Services

Habilitation Services

Chiropractic Care

Durable Medical Equipment

Hearing Aids

Imaging (CT/PET Scans, MRIs)

Preventive Care/Screening/Immunization

Routine Foot Care

Acupuncture

Weight Loss Programs

Routine Eye Exam for Children

Eye Glasses for Children

Dental Check-Up for Children

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy

Well Baby Visits and Care

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Basic Dental Care - Child

Orthodontia - Child

Major Dental Care - Child

Basic Dental Care - Adult

Orthodontia - Adult

Major Dental Care - Adult

Abortion for Which Public Funding is Prohibited

Transplant

Accidental Dental

Dialysis

Allergy Testing

Chemotherapy

Radiation

Diabetes Education

Prosthetic Devices

Infusion Therapy

Treatment for Temporomandibular Joint Disorders

Nutritional Counseling

Reconstructive Surgery

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Sheet 2: Cost Share Variances

To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required

Fields with a tilde "~" indicate a field that would be added for PY 2017 under this PRA package. Fields with a caret "^" indicates revisions that will be not be implemented for PY 2017 but will be included in PY 2018. Fields with a number sign (hash tag) "#" indicate a field that would be moved or removed under this PRA package.

Plan Cost Sharing Attributes HIOS Plan ID* (Standard Component + Variant)

Plan Cost Sharing Attributes Plan Marketing Name*~

Plan Cost Sharing Attributes Level of Coverage* (Metal Level)

Plan Cost Sharing Attributes CSR Variation Type*

Plan Cost Sharing Attributes Issuer Actuarial Value

Plan Cost Sharing Attributes AV Calculator Output Number*

Plan Cost Sharing Attributes Medical & Drug Deductibles Integrated?*

Plan Cost Sharing Attributes Medical & Drug Maximum Out of Pocket Integrated?*

Plan Cost Sharing Attributes Multiple In Network Tiers?*

Plan Cost Sharing Attributes 1st Tier Utilization*

Plan Cost Sharing Attributes 2nd Tier Utilization

AV Calculator Additional Benefit Design Maximum Coinsurance for Specialty Drugs^

AV Calculator Additional Benefit Design Maximum Number of Days for Charging an Inpatient Copay?^

AV Calculator Additional Benefit Design Which Benefits Begin Cost-Sharing After a Set Number of Visits? ^

AV Calculator Additional Benefit Design Number of Visits before Cost Sharing Begins^

AV Calculator Additional Benefit Design Which Benefits Begin Deductible/ Coinsurance After a Set Number of Copays? ^

AV Calculator Additional Benefit Design Number of Copays before Deductible/Coinsurance Begins^

SBC Scenario Having a Baby Deductible*

SBC Scenario Having a Baby Copayment*

SBC Scenario Having a Baby Coinsurance*

SBC Scenario Having a Baby Limit*

SBC Scenario Having Diabetes Deductible*

SBC Scenario Having Diabetes Copayment*

SBC Scenario Having Diabetes Coinsurance*

SBC Scenario Having Diabetes Limit*

SBC Scenario Simple Fracture Deductible~

SBC Scenario Simple Fracture Copayment~

SBC Scenario Simple Fracture Coinsurance~

SBC Scenario Simple Fracture Limit~

Maximum Out of Pocket for Medical EHB Benefits In Network Individual

Maximum Out of Pocket for Medical EHB Benefits In Network Family

Maximum Out of Pocket for Medical EHB Benefits In Network (Tier 2) Individual

Maximum Out of Pocket for Medical EHB Benefits In Network (Tier 2) Family

Maximum Out of Pocket for Medical EHB Benefits Out of Network Individual

Maximum Out of Pocket for Medical EHB Benefits Out of Network Family

Maximum Out of Pocket for Medical EHB Benefits Combined In/Out Network Individual

Maximum Out of Pocket for Medical EHB Benefits Combined In/Out Network Family

Maximum Out of Pocket for Drug EHB Benefits In Network Individual

Maximum Out of Pocket for Drug EHB Benefits In Network Family

Maximum Out of Pocket for Drug EHB Benefits In Network (Tier 2) Individual

Maximum Out of Pocket for Drug EHB Benefits In Network (Tier 2) Family

Maximum Out of Pocket for Drug EHB Benefits Out of Network Individual

Maximum Out of Pocket for Drug EHB Benefits Out of Network Family

Combined In/Out Network Individual

Maximum Out of Pocket for Drug EHB Benefits Combined In/Out Network Family

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Individual

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network Family

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network (Tier 2) Individual

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) In Network (Tier 2) Family

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Out of Network Individual

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Out of Network Family

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out Network Individual

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) Combined In/Out Network Family

Medical EHB Deductible In Network Individual

Medical EHB Deductible In Network Family

Medical EHB Deductible In Network Default Coinsurance

Medical EHB Deductible In Network (Tier 2) Individual

Medical EHB Deductible In Network (Tier 2) Family

Medical EHB Deductible In Network (Tier 2) Default Coinsurance

Medical EHB Deductible Out of Network Individual

Medical EHB Deductible Out of Network Family

Medical EHB Deductible Combined In/Out Network Individual

Medical EHB Deductible Combined In/Out Network Family

Drug EHB Deductible In Network Individual

Drug EHB Deductible In Network Family

Drug EHB Deductible In Network Default Coinsurance

Drug EHB Deductible In Network (Tier 2) Individual

Drug EHB Deductible In Network (Tier 2) Family

Drug EHB Deductible In Network (Tier 2) Default Coinsurance

Drug EHB Deductible Out of Network Individual

Drug EHB Deductible Out of Network Family

Drug EHB Deductible Combined In/Out Network Individual

Drug EHB Deductible Combined In/Out Network Family

Combined Medical and Drug EHB Deductible In Network Individual

Combined Medical and Drug EHB Deductible In Network Family

Combined Medical and Drug EHB Deductible In Network Default Coinsurance

Combined Medical and Drug EHB Deductible In Network (Tier 2) Individual

Combined Medical and Drug EHB Deductible In Network (Tier 2) Family

Combined Medical and Drug EHB Deductible In Network (Tier 2) Default Coinsurance

Combined Medical and Drug EHB Deductible Out of Network Individual

Combined Medical and Drug EHB Deductible Out of Network Family

Combined Medical and Drug EHB Deductible Combined In/Out Network Individual

Combined Medical and Drug EHB Deductible Combined In/Out Network Individual2

HSA/HRA Detail HSA Eligible*

HSA/HRA Detail HSA/HRA Employer Contribution

HSA/HRA Detail HSA/HRA Employer Contribution Amount

Plan Variant Level URLs URL for Summary of Benefits & Coverage

Plan Variant Level URLs Plan Brochure

Primary Care Visit to Treat an Injury or Illness Copay In Network (Tier 1)

Primary Care Visit to Treat an Injury or Illness Copay In Network (Tier 2)

Primary Care Visit to Treat an Injury or Illness Copay Out of Network

Primary Care Visit to Treat an Injury or Illness Coinsurance In Network (Tier 1)

Primary Care Visit to Treat an Injury or Illness Coinsurance In Network (Tier 2)

Primary Care Visit to Treat an Injury or Illness Coinsurance Out of Network

Mental Health and Substance Use Disorder Office Visit Copay In Network (Tier 1)^

Mental Health and Substance Use Disorder Office Visit Copay In Network (Tier 2)^

Mental Health and Substance Use Disorder Office Visit Copay Out of Network^

Mental Health and Substance Use Disorder Office Visit Coinsurance In Network (Tier 1)^

Mental Health and Substance Use Disorder Office Visit Coinsurance In Network (Tier 2)^

Mental Health and Substance Use Disorder Office Visit Coinsurance Out of Network^

All Other Mental Health/Substance Use Outpatient Visits Copay In Network (Tier 1)^

All Other Mental Health/Substance Use Outpatient Visits Copay In Network (Tier 2)^

All Other Mental Health/Substance Use Outpatient Visits Copay Out of Network^

All Other Mental Health/Substance Use Outpatient Visits Coinsurance In Network (Tier 1)^

All Other Mental Health/Substance Use Outpatient Visits Coinsurance In Network (Tier 2)^

All Other Mental Health/Substance Use Outpatient Visits Coinsurance Out of Network^

Specialist Visit Copay In Network (Tier 1)

Specialist Visit Copay In Network (Tier 2)

Specialist Visit Copay Out of Network

Specialist Visit Coinsurance In Network (Tier 1)

Specialist Visit Coinsurance In Network (Tier 2)

Specialist Visit Coinsurance Out of Network

Other Practitioner Office Visit (Nurse, Physician Assistant) Copay In Network (Tier 1)

Other Practitioner Office Visit (Nurse, Physician Assistant) Copay In Network (Tier 2)

Other Practitioner Office Visit (Nurse, Physician Assistant) Copay Out of Network

Other Practitioner Office Visit (Nurse, Physician Assistant) Coinsurance In Network (Tier 1)

Other Practitioner Office Visit (Nurse, Physician Assistant) Coinsurance In Network (Tier 2)

Other Practitioner Office Visit (Nurse, Physician Assistant) Coinsurance Out of Network

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Copay In Network (Tier 1)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Copay In Network (Tier 2)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Copay Out of Network

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Coinsurance In Network (Tier 1)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Coinsurance In Network (Tier 2)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Coinsurance Out of Network

Outpatient Surgery Physician/Surgical Services Copay In Network (Tier 1)

Outpatient Surgery Physician/Surgical Services Copay In Network (Tier 2)

Outpatient Surgery Physician/Surgical Services Copay Out of Network

Outpatient Surgery Physician/Surgical Services Coinsurance In Network (Tier 1)

Outpatient Surgery Physician/Surgical Services Coinsurance In Network (Tier 2)

Outpatient Surgery Physician/Surgical Services Coinsurance Out of Network

Hospice Services Copay In Network (Tier 1)

Hospice Services Copay In Network (Tier 2)

Hospice Services Copay Out of Network

Hospice Services Coinsurance In Network (Tier 1)

Hospice Services Coinsurance In Network (Tier 2)

Hospice Services Coinsurance Out of Network

Infertility Treatment Copay In Network (Tier 1)

Infertility Treatment Copay In Network (Tier 2)

Infertility Treatment Copay Out of Network

Infertility Treatment Coinsurance In Network (Tier 1)

Infertility Treatment Coinsurance In Network (Tier 2)

Infertility Treatment Coinsurance Out of Network

Urgent Care Centers or Facilities Copay In Network (Tier 1)

Urgent Care Centers or Facilities Copay In Network (Tier 2)

Urgent Care Centers or Facilities Copay Out of Network

Urgent Care Centers or Facilities Coinsurance In Network (Tier 1)

Urgent Care Centers or Facilities Coinsurance In Network (Tier 2)

Urgent Care Centers or Facilities Coinsurance Out of Network

Home Health Care Services Copay In Network (Tier 1)

Home Health Care Services Copay In Network (Tier 2)

Home Health Care Services Copay Out of Network

Home Health Care Services Coinsurance In Network (Tier 1)

Home Health Care Services Coinsurance In Network (Tier 2)

Home Health Care Services Coinsurance Out of Network

Emergency Room Services Copay In Network (Tier 1)

Emergency Room Services Copay In Network (Tier 2)

Emergency Room Services Copay Out of Network

Emergency Room Services Coinsurance In Network (Tier 1)

Emergency Room Services Coinsurance In Network (Tier 2)

Emergency Room Services Coinsurance Out of Network

Mental Health Emergency Services Copay In Network (Tier 1)^

Mental Health Emergency Services Copay In Network (Tier 2)^

Mental Health Emergency Services Copay Out of Network^

Mental Health Emergency Services Coinsurance In Network (Tier 1)^

Mental Health Emergency Services Coinsurance In Network (Tier 2)^

Mental Health Emergency Services Coinsurance Out of Network^

Emergency Transportation/Ambulance Copay In Network (Tier 1)

Emergency Transportation/Ambulance Copay In Network (Tier 2)

Emergency Transportation/Ambulance Copay Out of Network

Emergency Transportation/Ambulance Coinsurance In Network (Tier 1)

Emergency Transportation/Ambulance Coinsurance In Network (Tier 2)

Emergency Transportation/Ambulance Coinsurance Out of Network

Inpatient Hospital Services (e.g., Hospital Stay) Copay In Network (Tier 1)

Inpatient Hospital Services (e.g., Hospital Stay) Copay In Network (Tier 2)

Inpatient Hospital Services (e.g., Hospital Stay) Copay Out of Network

Inpatient Hospital Services (e.g., Hospital Stay) Coinsurance In Network (Tier 1)

Inpatient Hospital Services (e.g., Hospital Stay) Coinsurance In Network (Tier 2)

Inpatient Hospital Services (e.g., Hospital Stay) Coinsurance Out of Network

Inpatient Physician and Surgical Services Copay In Network (Tier 1)

Inpatient Physician and Surgical Services Copay In Network (Tier 2)

Inpatient Physician and Surgical Services Copay Out of Network

Inpatient Physician and Surgical Services Coinsurance In Network (Tier 1)

Inpatient Physician and Surgical Services Coinsurance In Network (Tier 2)

Inpatient Physician and Surgical Services Coinsurance Out of Network

Bariatric Surgery Copay In Network (Tier 1)

Bariatric Surgery Copay In Network (Tier 2)

Bariatric Surgery Copay Out of Network

Bariatric Surgery Coinsurance In Network (Tier 1)

Bariatric Surgery Coinsurance In Network (Tier 2)

Bariatric Surgery Coinsurance Out of Network

Skilled Nursing Facility Copay In Network (Tier 1)

Skilled Nursing Facility Copay In Network (Tier 2)

Skilled Nursing Facility Copay Out of Network

Skilled Nursing Facility Coinsurance In Network (Tier 1)

Skilled Nursing Facility Coinsurance In Network (Tier 2)

Skilled Nursing Facility Coinsurance Out of Network

Prenatal and Postnatal Care Copay In Network (Tier 1)

Prenatal and Postnatal Care Copay In Network (Tier 2)

Prenatal and Postnatal Care Copay Out of Network

Prenatal and Postnatal Care Coinsurance In Network (Tier 1)

Prenatal and Postnatal Care Coinsurance In Network (Tier 2)

Prenatal and Postnatal Care Coinsurance Out of Network

Delivery and All Inpatient Services for Maternity Care Copay In Network (Tier 1)

Delivery and All Inpatient Services for Maternity Care Copay In Network (Tier 2)

Delivery and All Inpatient Services for Maternity Care Copay Out of Network

Delivery and All Inpatient Services for Maternity Care Coinsurance In Network (Tier 1)

Delivery and All Inpatient Services for Maternity Care Coinsurance In Network (Tier 2)

Delivery and All Inpatient Services for Maternity Care Coinsurance Out of Network

Mental/Behavioral Health Outpatient Services Copay In Network (Tier 1)

Mental/Behavioral Health Outpatient Services Copay In Network (Tier 2)

Mental/Behavioral Health Outpatient Services Copay Out of Network

Mental/Behavioral Health Outpatient Services Coinsurance In Network (Tier 1)

Mental/Behavioral Health Outpatient Services Coinsurance In Network (Tier 2)

Mental/Behavioral Health Outpatient Services Coinsurance Out of Network

Mental/Behavioral Health Inpatient Services Copay In Network (Tier 1)

Mental/Behavioral Health Inpatient Services Copay In Network (Tier 2)

Mental/Behavioral Health Inpatient Services Copay Out of Network

Mental/Behavioral Health Inpatient Services Coinsurance In Network (Tier 1)

Mental/Behavioral Health Inpatient Services Coinsurance In Network (Tier 2)

Mental/Behavioral Health Inpatient Services Coinsurance Out of Network

Substance Abuse Disorder Outpatient Services Copay In Network (Tier 1)

Substance Abuse Disorder Outpatient Services Copay In Network (Tier 2)

Substance Abuse Disorder Outpatient Services Copay Out of Network

Substance Abuse Disorder Outpatient Services Coinsurance In Network (Tier 1)

Substance Abuse Disorder Outpatient Services Coinsurance In Network (Tier 2)

Substance Abuse Disorder Outpatient Services Coinsurance Out of Network

Substance Abuse Disorder Inpatient Services Copay In Network (Tier 1)

Substance Abuse Disorder Inpatient Services Copay In Network (Tier 2)

Substance Abuse Disorder Inpatient Services Copay Out of Network

Substance Abuse Disorder Inpatient Services Coinsurance In Network (Tier 1)

Substance Abuse Disorder Inpatient Services Coinsurance In Network (Tier 2)

Substance Abuse Disorder Inpatient Services Coinsurance Out of Network

Generic Drugs Copay In Network (Tier 1)

Generic Drugs Copay In Network (Tier 2)

Generic Drugs Copay Out of Network

Generic Drugs Coinsurance In Network (Tier 1)

Generic Drugs Coinsurance In Network (Tier 2)

Generic Drugs Coinsurance Out of Network

Preferred Brand Drugs Copay In Network (Tier 1)

Preferred Brand Drugs Copay In Network (Tier 2)

Preferred Brand Drugs Copay Out of Network

Preferred Brand Drugs Coinsurance In Network (Tier 1)

Preferred Brand Drugs Coinsurance In Network (Tier 2)

Preferred Brand Drugs Coinsurance Out of Network

Non-Preferred Brand Drugs Copay In Network (Tier 1)

Non-Preferred Brand Drugs Copay In Network (Tier 2)

Non-Preferred Brand Drugs Copay Out of Network

Non-Preferred Brand Drugs Coinsurance In Network (Tier 1)

Non-Preferred Brand Drugs Coinsurance In Network (Tier 2)

Non-Preferred Brand Drugs Coinsurance Out of Network

Specialty Drugs Copay In Network (Tier 1)

Specialty Drugs Copay In Network (Tier 2)

Specialty Drugs Copay Out of Network

Specialty Drugs Coinsurance In Network (Tier 1)

Specialty Drugs Coinsurance In Network (Tier 2)

Specialty Drugs Coinsurance Out of Network

Outpatient Rehabilitation Services Copay In Network (Tier 1)

Outpatient Rehabilitation Services Copay In Network (Tier 2)

Outpatient Rehabilitation Services Copay Out of Network

Outpatient Rehabilitation Services Coinsurance In Network (Tier 1)

Outpatient Rehabilitation Services Coinsurance In Network (Tier 2)

Outpatient Rehabilitation Services Coinsurance Out of Network

Habilitation Services Copay In Network (Tier 1)

Habilitation Services Copay In Network (Tier 2)

Habilitation Services Copay Out of Network

Habilitation Services Coinsurance In Network (Tier 1)

Habilitation Services Coinsurance In Network (Tier 2)

Habilitation Services Coinsurance Out of Network

Chiropractic Care Copay In Network (Tier 1)

Chiropractic Care Copay In Network (Tier 2)

Chiropractic Care Copay Out of Network

Chiropractic Care Coinsurance In Network (Tier 1)

Chiropractic Care Coinsurance In Network (Tier 2)

Chiropractic Care Coinsurance Out of Network

Durable Medical Equipment Copay In Network (Tier 1)

Durable Medical Equipment Copay In Network (Tier 2)

Durable Medical Equipment Copay Out of Network

Durable Medical Equipment Coinsurance In Network (Tier 1)

Durable Medical Equipment Coinsurance In Network (Tier 2)

Durable Medical Equipment Coinsurance Out of Network

Hearing Aids Copay In Network (Tier 1)

Hearing Aids Copay In Network (Tier 2)

Hearing Aids Copay Out of Network

Hearing Aids Coinsurance In Network (Tier 1)

Hearing Aids Coinsurance In Network (Tier 2)

Hearing Aids Coinsurance Out of Network

Imaging (CT/PET Scans, MRIs) Copay In Network (Tier 1)

Imaging (CT/PET Scans, MRIs) Copay In Network (Tier 2)

Imaging (CT/PET Scans, MRIs) Copay Out of Network

Imaging (CT/PET Scans, MRIs) Coinsurance In Network (Tier 1)

Imaging (CT/PET Scans, MRIs) Coinsurance In Network (Tier 2)

Imaging (CT/PET Scans, MRIs) Coinsurance Out of Network

Preventive Care/Screening/Immunization Copay In Network (Tier 1)

Preventive Care/Screening/Immunization Copay In Network (Tier 2)

Preventive Care/Screening/Immunization Copay Out of Network

Preventive Care/Screening/Immunization Coinsurance In Network (Tier 1)

Preventive Care/Screening/Immunization Coinsurance In Network (Tier 2)

Preventive Care/Screening/Immunization Coinsurance Out of Network

Routine Eye Exam for Children Copay In Network (Tier 1)

Routine Eye Exam for Children Copay In Network (Tier 2)

Routine Eye Exam for Children Copay Out of Network

Routine Eye Exam for Children Coinsurance In Network (Tier 1)

Routine Eye Exam for Children Coinsurance In Network (Tier 2)

Routine Eye Exam for Children Coinsurance Out of Network

Eye Glasses for Children Copay In Network (Tier 1)

Eye Glasses for Children Copay In Network (Tier 2)

Eye Glasses for Children Copay Out of Network

Eye Glasses for Children Coinsurance In Network (Tier 1)

Eye Glasses for Children Coinsurance In Network (Tier 2)

Eye Glasses for Children Coinsurance Out of Network

Rehabilitative Speech Therapy Copay In Network (Tier 1)

Rehabilitative Speech Therapy Copay In Network (Tier 2)

Rehabilitative Speech Therapy Copay Out of Network

Rehabilitative Speech Therapy Coinsurance In Network (Tier 1)

Rehabilitative Speech Therapy Coinsurance In Network (Tier 2)

Rehabilitative Speech Therapy Coinsurance Out of Network

Rehabilitative Occupational and Rehabilitative Physical Therapy Copay In Network (Tier 1)

Rehabilitative Occupational and Rehabilitative Physical Therapy Copay In Network (Tier 2)

Rehabilitative Occupational and Rehabilitative Physical Therapy Copay Out of Network

Rehabilitative Occupational and Rehabilitative Physical Therapy Coinsurance In Network (Tier 1)

Rehabilitative Occupational and Rehabilitative Physical Therapy Coinsurance In Network (Tier 2)

Rehabilitative Occupational and Rehabilitative Physical Therapy Coinsurance Out of Network

Well Baby Visits and Care Copay In Network (Tier 1)

Well Baby Visits and Care Copay In Network (Tier 2)

Well Baby Visits and Care Copay Out of Network

Well Baby Visits and Care Coinsurance In Network (Tier 1)

Well Baby Visits and Care Coinsurance In Network (Tier 2)

Well Baby Visits and Care Coinsurance Out of Network

Laboratory Outpatient and Professional Services Copay In Network (Tier 1)

Laboratory Outpatient and Professional Services Copay In Network (Tier 2)

Laboratory Outpatient and Professional Services Copay Out of Network

Laboratory Outpatient and Professional Services Coinsurance In Network (Tier 1)

Laboratory Outpatient and Professional Services Coinsurance In Network (Tier 2)

Laboratory Outpatient and Professional Services Coinsurance Out of Network

X-rays and Diagnostic Imaging Copay In Network (Tier 1)

X-rays and Diagnostic Imaging Copay In Network (Tier 2)

X-rays and Diagnostic Imaging Copay Out of Network

X-rays and Diagnostic Imaging Coinsurance In Network (Tier 1)

X-rays and Diagnostic Imaging Coinsurance In Network (Tier 2)

X-rays and Diagnostic Imaging Coinsurance Out of Network

Transplant Copay In Network (Tier 1)

Transplant Copay In Network (Tier 2)

Transplant Copay Out of Network

Transplant Coinsurance In Network (Tier 1)

Transplant Coinsurance In Network (Tier 2)

Transplant Coinsurance Out of Network

Accidental Dental Copay In Network (Tier 1)

Accidental Dental Copay In Network (Tier 2)

Accidental Dental Copay Out of Network

Accidental Dental Coinsurance In Network (Tier 1)

Accidental Dental Coinsurance In Network (Tier 2)

Accidental Dental Coinsurance Out of Network

Dialysis Copay In Network (Tier 1)

Dialysis Copay In Network (Tier 2)

Dialysis Copay Out of Network

Dialysis Coinsurance In Network (Tier 1)

Dialysis Coinsurance In Network (Tier 2)

Dialysis Coinsurance Out of Network

Chemotherapy Copay In Network (Tier 1)

Chemotherapy Copay In Network (Tier 2)

Chemotherapy Copay Out of Network

Chemotherapy Coinsurance In Network (Tier 1)

Chemotherapy Coinsurance In Network (Tier 2)

Chemotherapy Coinsurance Out of Network

Radiation Copay In Network (Tier 1)

Radiation Copay In Network (Tier 2)

Radiation Copay Out of Network

Radiation Coinsurance In Network (Tier 1)

Radiation Coinsurance In Network (Tier 2)

Radiation Coinsurance Out of Network

Prosthetic Devices Copay In Network (Tier 1)

Prosthetic Devices Copay In Network (Tier 2)

Prosthetic Devices Copay Out of Network

Prosthetic Devices Coinsurance In Network (Tier 1)

Prosthetic Devices Coinsurance In Network (Tier 2)

Prosthetic Devices Coinsurance Out of Network

Infusion Therapy Copay In Network (Tier 1)

Infusion Therapy Copay In Network (Tier 2)

Infusion Therapy Copay Out of Network

Infusion Therapy Coinsurance In Network (Tier 1)

Infusion Therapy Coinsurance In Network (Tier 2)

Infusion Therapy Coinsurance Out of Network

Treatment for Temporomandibular Joint Disorders Copay In Network (Tier 1)

Treatment for Temporomandibular Joint Disorders Copay In Network (Tier 2)

Treatment for Temporomandibular Joint Disorders Copay Out of Network

Treatment for Temporomandibular Joint Disorders Coinsurance In Network (Tier 1)

Treatment for Temporomandibular Joint Disorders Coinsurance In Network (Tier 2)

Treatment for Temporomandibular Joint Disorders Coinsurance Out of Network

Nutritional Counseling Copay In Network (Tier 1)

Nutritional Counseling Copay In Network (Tier 2)

Nutritional Counseling Copay Out of Network

Nutritional Counseling Coinsurance In Network (Tier 1)

Nutritional Counseling Coinsurance In Network (Tier 2)

Nutritional Counseling Coinsurance Out of Network

Reconstructive Surgery Copay In Network (Tier 1)

Reconstructive Surgery Copay In Network (Tier 2)

Reconstructive Surgery Copay Out of Network

Reconstructive Surgery Coinsurance In Network (Tier 1)

Reconstructive Surgery Coinsurance In Network (Tier 2)

Reconstructive Surgery Coinsurance Out of Network