OptimaFit Bronze 6250 20% HSA Direct M - 20507VA1410008 Health Insurance Plan

Limit: 30.0 Visit(s) per Benefit Period

30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached.

This plan contracts with birthing centers.

Covered Services include diagnostic x-ray, lab services, medical supplies, and advanced diagnostic imaging, such as MRIs and CT scans to evaluate and Stabilize a patient with an Emergency Medical Condition. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Limit: 1.0 Item(s) per Benefit Period

Includes one pair of standard single vision, bifocal, trifocal, or progressive eyeglass lenses and one frame per benefit period. This Plan only covers a choice of contact lenses or eyeglasses, but not both. The Plan will not cover any additional services after the limits have been reached. Materials must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

Limit: 30.0 Visit(s) per Benefit Period

Include services and devices that help a member keep, learn or improve skills and functioning for daily living, and other services for people with disabilities in a variety of inpatient and outpatient settings or facilities. Visit limits may apply. See individual therapy limits. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Limit: 100.0 Visit(s) per Benefit Period

100 Visits per Benefit Period. The Plan will not cover any additional services after the limits have been reached.

Include surgery and services received during an inpatient stay that are required to treat medical condition, illness, or injury. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include professional services received while receiving covered services in an inpatient hospital. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

Copayment or Coinsurance applies to services provided in a free-standing ambulatory surgery center or Hospital outpatient surgical facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Visit limits may apply. See individual therapy limits. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Include professional services received while receiving covered services in a free-standing outpatient facility, or a hospital outpatient facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include brand-name drugs and some generic drugs with higher costs than Tier 1 generics that are considered by the Plan to be standard therapy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

Applies to Covered Services done during an office visit, including doctor visits in the home and online visits. You will pay an additional Copayment or Coinsurance for outpatient Habilitative and Rehabilitative therapy and services, injectable and infused medications, allergy care, testing and serum, outpatient advanced imaging procedures, and sleep studies done during an office visit. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Limit: 16.0 Hours per Benefit Period

16 Hours per Benefit Period. The Plan will not cover any additional services after the limits have been reached.

Limit: 30.0 Visit(s) per Benefit Period

30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Limit: 30.0 Visit(s) per Benefit Period

30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Limit: 1.0 Exam(s) per Benefit Period

Includes one exam per benefit period. The Plan will not cover any additional services after the limits have been reached. Low vision exams are limited to one every 5 years. Exams must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Limit: 100.0 Days per Stay

Following inpatient Hospital care or in lieu of hospitalization when, in the Plan?s judgment, skilled services are required. Services include up to 100 days per stay. The Plan will not cover any additional services after the limits have been reached. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include those drugs classified by the Plan as Specialty Drugs and compound prescription medications. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.

Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details.