Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care50% coinsurance after deductibleNoneSpecialist Care50% coinsurance after deductibleNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace HSA Eligible Bronze LimitedLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BHSA Bronze Limited1OH-EXCM-1046HighlightsAnnual Deductible* Individual: $5,300 Family: $10,600Coinsurance50%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,750Family: $13,500* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $5,300 of covered services each benefit year before CareSource begins to pay for any covered service where the annual deductible applies. For family coverage, you are responsible for paying the first $10,600 for covered services for your entire family each benefit year before CareSource begins to pay for any covered service where the annual deductible applies. However, for each individual covered member within your family, the maximum amount each member would pay toward the family deductible is the individual deductible amount, in this case $5,300 up to the family maximum of $10,600. The annual deductible applies to covered services identified as after deductible in the Covered Service table below. ** See Section 13: Evidence of Coverage Glossary for the definition of annual out-of-pocket maximum. For family coverage, each individual covered member within your family is contributing toward the family annual out-of-pocket maximum. However, for each individual covered member within your family, the maximum amount each member would pay toward the family annual out-of-pocket maximum is the individual out-of-pocket maximum, which is $6,750. Once a member has reached their out-of-pocket maximum, the plan will pay 100% of their covered services. Your Evidence of Coverage explains which benefits accrue to your out-of-pocket maximum.BNHPlan InformationPrimary MemberMember IDDate of BirthEffective DateLast Coverage Change DateDependent InformationDependent NameRelationship to You Date of Birth Effective Date[John Doe][104000000][01/01/1965][01/01/2020][01/01/2019][Nancy Doe][Spouse][01/01/1966][01/01/2020]This summary shows in-network benets only. Learn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BHSA Bronze Limited2OH-EXCM-1046BNHCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 50% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology50% coinsurance after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)50% coinsurance after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic50% coinsurance after deductiblePrior authorization requiredInpatient Services Facility/Physician50% coinsurance after deductiblePrior authorization requiredSkilled Nursing Facility50% coinsurance after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician50% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care 50% coinsurance after deductibleNoneInpatient Services50% coinsurance after deductiblePrior authorization requiredOutpatient Services50% coinsurance after deductibleMay require prior authorizationUrgent Care 50% coinsurance after deductibleNoneAmbulance Services 50% coinsurance after deductibleFor both in-network and out-of-network providersPrior authorization is not required for emergency ambulance transportation or for facility to facility transfers. All other ambulance transportation requires prior authorization.Emergency Health Care Services 50% coinsurance after deductibleFor both in-network and out-of-network providersIf admitted to the hospital directly from the Emergency Department, these services will be covered the same as inpatient services and the applicable Copayment and Coinsurance will apply.AutismPhysical Therapy50% coinsurance after deductible20 visits per benefit yearOccupational Therapy50% coinsurance after deductible20 visits per benefit yearSpeech Therapy50% coinsurance after deductible20 visits per benefit yearBehavioral Therapy50% coinsurance after deductibleNoneHabilitative ServicesPhysical Therapy50% coinsurance after deductible20 visits per benefit yearOccupational Therapy50% coinsurance after deductible20 visits per benefit yearSpeech Therapy50% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy 50% coinsurance after deductible20 visits per benefit yearOccupational Therapy50% coinsurance after deductible20 visits per benefit yearSpeech Therapy50% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services50% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation50% coinsurance after deductible20 visits per benefit yearChiropractic Services50% coinsurance after deductibleManipulation therapy-12 visits per benefit yearLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BHSA Bronze Limited3OH-EXCM-1046BNHCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Behavioral Health ServicesCovered the same as office visits, inpatient services, and outpatient servicesPrior authorization is required for all inpatient stays and residential treatment programs. Partial hospitalization programs and intensive outpatient services may require prior authorization.Transplant ServicesCovered the same as office visits, inpatient services, and outpatient servicesPrior authorization requiredTemporomandibular/Craniomandibular Joint Disorder and Craniomandibular Jaw DisorderCovered the same as office visits, inpatient services, and outpatient servicesPrior authorization requiredPrivate Duty Nursing 50% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 50% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care50% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation50% coinsurance after deductibleNoneEquipment 50% coinsurance after deductibleNoneSupplies50% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances50% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)50% coinsurance after deductibleTier 2 (Preferred)50% coinsurance after deductibleTier 3 (Non-Preferred)50% coinsurance after deductibleTier 4 (Specialty Preferred)50% coinsurance after deductibleTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleMail Order May require prior authorizationTier 0 (Preventive)No chargeUp to a 90-day supplyTier 1 (Low Cost)50% coinsurance after deductibleUp to a 90-day supplyTier 2 (Preferred)50% coinsurance after deductibleUp to a 90-day supplyTier 3 (Non-Preferred)50% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)50% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supplyCovered ServiceYou Pay (Network Providers Only) Limit (If Applicable)Vision (pediatric)Childrens Eye Exam 50% coinsurance after deductible1 routine eye exam per benefit yearLow Vision Testing and Aids No chargeLimited to one evaluation and aid per benefit year.Childrens Eyewear 50% coinsurance after deductibleLimited to one pair of glasses or contact lenses once per benefit year. If medically necessary, a replacement pair of glasses is allowed.Dental (accidental injury) 50% coinsurance after deductibleInjury as a result of chewing or biting is not considered an accidental injury.Dental (pediatric)Childrens Dental Check-up 50% coinsurance after deductible2 dental check-ups per benefit yearBasic/Major Restorative 50% coinsurance after deductible NoneOrthodontic 50% coinsurance after deductible Prior authorization is required for medically necessary orthodontia. No limit for medically necessary orthodontia. Prior Authorization: Some health care services require prior authorization from the Plan. Prior authorization is the process used by the Plan to determine those health care services listed on the Plans prior authorization list that meet evidence-based criteria for medical necessity and are covered services under the Plan prior to the health care service being provided. Your Network Provider is responsible for obtaining Prior Authorization for the Health Care Services described on the Prior Authorization List. If you receive Health Care Services from a Non-Network Provider, either you or the Non-Network Provider must obtain Prior Authorization. If Prior Authorization is not obtained, you are responsible for making full payment to the Non-Network Provider. Please refer to Section 2 of the Evidence of Coverage at www.caresource.com/marketplace for complete details after you are enrolled. This Schedule of Benefits is a summary of your financial responsibility when you receive health care services from a physician, pharmacy, facility, or other provider. All covered services are subject to the conditions, exclusions, limitations, terms, and rules of the Evidence of Coverage including any rider/enhancements or amendments. Except as otherwise provided in the Evidence of Coverage, covered services must be provided to you by a network provider and medically necessary. The Plan does not cover all health care service expenses. In the event of any discrepancy between this Schedule of Benefits and your Evidence of Coverage, the Evidence of Coverage shall control. For more detailed information about your c overed services, please refe r to the Evidence of Coverage at www.caresource.com/marketplace. For covered services listed in the Evidence of Coverage that are not specifically listed on this Schedule of Benefits, the cost sharing is equal to the coinsurance after the deductible.The copays and coinsurance listed in the You Pay column would only apply if the item or service is not furnished directly by a provider meeting the criteria outlined below, otherwise there would be no cost to you. 1) an Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (each as defined in 25 U.S.C. 1603);2) a provider who was referred by one of the organizations listed in item 1. Your CareSource marketplace plan was designed to meet certain requirements set by the Internal Revenue Service and qualifies as a high deductible health plan (HDHP). As such, your CareSource marketplace plan is compatible for use with a Health Savings Account (HSA). However, please be aware that CareSource is not offering or administering an HSA in conjunction with your CareSource marketplace HDHP. In addition, your enrollment in a CareSource marketplace HDHP is only one of the eligibility requirements for establishing and maintaining an HSA. You are responsible for determining whether you are eligible to establish an HSA. You should consult your financial, tax, or legal advisor for more information regarding your obligations and eligibility for establishing and maintaining an HSA.Learn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BHSA Bronze Limited 4OH-EXCM-1046BNH ARABIC . .CareSource . . .AMHARIC CareSource 1-800-479-9502 TTY:711 BURMESE CareSource GUJARATI . CareSource . . . . 1-800-479-9502 TTY:711 .HINDI CareSource , 1-800-479-9502 TTY:711. ITALIAN Questa comunicazione contiene informazioni importanti. Questa comunicazione contiene informazioni importanti circa la sua iscrizione o copertura tramite CareSource. Cerchi le date principali in questa comunicazione. Potrebbe dover intraprendere delle azioni entro certe scadenze per mantenere la Sua copertura sanitaria o per contribuire ai costi. Ha il diritto di avere queste informazioni e supporto nella Sua lingua, senza alcun costo. Chiami il 1-800-479-9502 TTY:711. JAPANESE M3T*/&aoI’a 6QbJtCareSource M3T*/&aM8t!gu7KI]2CU1-800-479-9502 TTY:711 KOREAN . CareSource . . . . : 1-800-479-9502 TTY:711. PENNSYLVANIA DUTCH Die Bekanntmaching gebt wichdichi Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei Application oder Coverage mit CareSource. Geb Acht fer wichdiche Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes duh muscht, an beschtimmde Deadlines, so ass du dei Health Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du hoscht es Recht fer die Information un Hilf in deinre eegne Schprooch griege, un die Hilf koschtet nix. 1-800-479-9502 TTY:711. RUSSIAN -, , CareSource, . , 1-800-479-9502 TTY:711. SPANISH Este aviso incluye informacin importante. Este aviso incluye informacin importante sobre su solicitud o su cobertura de CareSource. Busque las fechas clave en este aviso. Es probable que deba realizar acciones dentro de determinado plazo para mantener su cobertura mdica o recibir ayuda con los costos. Tiene derecho a recibir esta informacin y ayuda en su propio idioma sin costo. Llame al 1-800-479-9502 TTY:711. UKRAINIAN . CareSource. . , . . 1-800-479-9502 TTY:711. VIETNAMESE Thng bo ny c thng tin quan trng. Thng bo ny c thng tin quan trng v n xin hoc bo him ca bn thng qua CareSource. Hy xem nhng ngy quan trng trong thng bo ny.Bn c th cn phi hnh ng trc mt s thi hn nht nh duy tr bo him sc khe ca mnh hay c tr gip c tr ph. Bn c quyn c nhn thng tin ny v c tr gip bng ngn ng ca mnh min ph. Vui lng gi s 1-800-479-9502 TTY:711.This Notice has Important Information. This notice has important information about your application or coverage through CareSource. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 1-800-479-9502 TTY:711.1-800-479-9502 TTY:711. OH-EXCM-0461 2016 CareSource. All Rights Reserved MPNon-DDTagline(OH2018)-04613.0)/v4%#0@ 1-800-479-9502 TTY:711 30 -#02.030/# @ %'z )E %'#@CHINESE =bJt%&d"p2 =bJt%&$!37IG^!t&Y &