Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$60 copayNoneSpecialist Care$120 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace BronzeLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-B Bronze1OH-EXCM-1026HighlightsAnnual Deductible* Individual: $7,700 Family: $15,400Coinsurance50%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $8,150Family: $16,300* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $7,700 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 $15,400 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 $7,700 up to the family maximum of $15,400. 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 $8,150. 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.BPlan 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)-B Bronze2OH-EXCM-1026BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 50% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$125 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)50% coinsurance after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$125 copay 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 $120 copayNoneInpatient 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 Therapy$60 copay20 visits per benefit yearOccupational Therapy$60 copay20 visits per benefit yearSpeech Therapy50% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$60 copayNoneHabilitative ServicesPhysical Therapy$60 copay20 visits per benefit yearOccupational Therapy$60 copay20 visits per benefit yearSpeech Therapy50% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $60 copay20 visits per benefit yearOccupational Therapy$60 copay20 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)-B Bronze3OH-EXCM-1026BCovered 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)$40 copayTier 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)$100 copayUp 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 supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$5 copayNoneSpecialist Care$15 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard Silver 3Learn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver 31OH-EXCM-1025HighlightsAnnual Deductible* Individual: $400 Family: $800Coinsurance5%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $750Family: $1,500* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $400 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 $800 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 $400 up to the family maximum of $800. 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 $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.BPlan 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)-BS Silver 32OH-EXCM-1025BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 5% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$50 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)$100 copay after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$50 copay after deductiblePrior authorization requiredInpatient Services Facility/Physician$150 copay after deductiblePrior authorization requiredSkilled Nursing Facility$150 copay after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician5% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $15 copayNoneInpatient Services$150 copay after deductiblePrior authorization requiredOutpatient Services5% coinsurance after deductibleMay require prior authorizationUrgent Care $25 copayNoneAmbulance Services 5% 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 $150 copay 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 Therapy$5 copay20 visits per benefit yearOccupational Therapy$5 copay20 visits per benefit yearSpeech Therapy5% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$5 copayNoneHabilitative ServicesPhysical Therapy$5 copay20 visits per benefit yearOccupational Therapy$5 copay20 visits per benefit yearSpeech Therapy5% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $5 copay20 visits per benefit yearOccupational Therapy$5 copay20 visits per benefit yearSpeech Therapy5% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services5% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation5% coinsurance after deductible20 visits per benefit yearChiropractic Services5% 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)-BS Silver 33OH-EXCM-1025BCovered 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 5% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 5% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care5% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation5% coinsurance after deductibleNoneEquipment 5% coinsurance after deductibleNoneSupplies5% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances5% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$5 copayTier 2 (Preferred)$15 copayTier 3 (Non-Preferred)5% coinsurance after deductibleTier 4 (Specialty Preferred)5% 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)$12.50 copayUp to a 90-day supplyTier 2 (Preferred)$37.50 copayUp to a 90-day supplyTier 3 (Non-Preferred)5% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)5% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$10 copayNoneSpecialist Care$30 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard Silver 2Learn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver 21OH-EXCM-1024HighlightsAnnual Deductible* Individual: $1,000 Family: $2,000Coinsurance10%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $2,000Family: $4,000* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $1,000 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 $2,000 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 $1,000 up to the family maximum of $2,000. 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 $2,000. 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.BPlan 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)-BS Silver 22OH-EXCM-1024BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 10% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$150 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)$200 copay after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$150 copay after deductiblePrior authorization requiredInpatient Services Facility/Physician$250 copay after deductiblePrior authorization requiredSkilled Nursing Facility$250 copay after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician10% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $30 copayNoneInpatient Services$250 copay after deductiblePrior authorization requiredOutpatient Services10% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 10% 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 $250 copay 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 Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy10% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$10 copayNoneHabilitative ServicesPhysical Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy10% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy10% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services10% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation10% coinsurance after deductible20 visits per benefit yearChiropractic Services10% 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)-BS Silver 23OH-EXCM-1024BCovered 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 10% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 10% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care10% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation10% coinsurance after deductibleNoneEquipment 10% coinsurance after deductibleNoneSupplies10% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances10% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$15 copayTier 2 (Preferred)$40 copayTier 3 (Non-Preferred)10% coinsurance after deductibleTier 4 (Specialty Preferred)10% 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)$37.50 copayUp to a 90-day supplyTier 2 (Preferred)$100 copayUp to a 90-day supplyTier 3 (Non-Preferred)10% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)10% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$20 copayNoneSpecialist Care$40 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard Silver 1Learn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver 11OH-EXCM-1023HighlightsAnnual Deductible* Individual: $5,500 Family: $11,000Coinsurance20%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,000Family: $12,000* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $5,500 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 $11,000 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 $5,500 up to the family maximum of $11,000. 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 $6,000. 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.BPlan 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)-BS Silver 12OH-EXCM-1023BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 20% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$175 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)$225 copay after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$175 copay after deductiblePrior authorization requiredInpatient Services Facility/Physician$400 copay after deductiblePrior authorization requiredSkilled Nursing Facility$400 copay after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician20% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $40 copayNoneInpatient Services$400 copay after deductiblePrior authorization requiredOutpatient Services20% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 20% 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 $400 copay 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 Therapy$20 copay20 visits per benefit yearOccupational Therapy$20 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$20 copayNoneHabilitative ServicesPhysical Therapy$20 copay20 visits per benefit yearOccupational Therapy$20 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $20 copay20 visits per benefit yearOccupational Therapy$20 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services20% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation20% coinsurance after deductible20 visits per benefit yearChiropractic Services20% 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)-BS Silver 13OH-EXCM-1023BCovered 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 20% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 20% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care20% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation20% coinsurance after deductibleNoneEquipment 20% coinsurance after deductibleNoneSupplies20% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances20% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$20 copayTier 2 (Preferred)$45 copayTier 3 (Non-Preferred)20% coinsurance after deductibleTier 4 (Specialty Preferred)20% 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 copayUp to a 90-day supplyTier 2 (Preferred)$112.50 copayUp to a 90-day supplyTier 3 (Non-Preferred)20% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)20% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$25 copayNoneSpecialist Care$60 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard Silver LimitedLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver Limited1OH-EXCM-1022HighlightsAnnual Deductible* Individual: $5,900 Family: $11,800Coinsurance20%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,800Family: $13,600* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $5,900 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 $11,800 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 $5,900 up to the family maximum of $11,800. 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 $6,800. 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.BNPlan 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)-BS Silver Limited2OH-EXCM-1022BNCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 20% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$200 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)$250 copay after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$200 copay after deductiblePrior authorization requiredInpatient Services Facility/Physician$500 copay after deductiblePrior authorization requiredSkilled Nursing Facility$500 copay after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician20% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $60 copayNoneInpatient Services$500 copay after deductiblePrior authorization requiredOutpatient Services20% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 20% 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 $500 copay 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 Therapy$25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$25 copayNoneHabilitative ServicesPhysical Therapy$25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services20% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation20% coinsurance after deductible20 visits per benefit yearChiropractic Services20% 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)-BS Silver Limited3OH-EXCM-1022BNCovered 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 20% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 20% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care20% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation20% coinsurance after deductibleNoneEquipment 20% coinsurance after deductibleNoneSupplies20% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances20% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$30 copayTier 2 (Preferred)$60 copayTier 3 (Non-Preferred)20% coinsurance after deductibleTier 4 (Specialty Preferred)20% 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)$75 copayUp to a 90-day supplyTier 2 (Preferred)$150 copayUp to a 90-day supplyTier 3 (Non-Preferred)20% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)20% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary CareNo chargeNoneSpecialist CareNo chargeNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard Silver ZeroLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver Zero1OH-EXCM-1021HighlightsAnnual Deductible* Individual: $0 Family: $0Coinsurance0%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $0Family: $0* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $0 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 $0 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 $0 up to the family maximum of $0. 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 $0. 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.BZPlan 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)-BS Silver Zero2OH-EXCM-1021BZCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab No chargeMay require prior authorizationX-Ray/RadiologyNo chargeMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)No chargePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnosticNo chargePrior authorization requiredInpatient Services Facility/PhysicianNo chargePrior authorization requiredSkilled Nursing FacilityNo chargePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/PhysicianNo chargeMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care No chargeNoneInpatient ServicesNo chargePrior authorization requiredOutpatient ServicesNo chargeMay require prior authorizationUrgent Care No chargeNoneAmbulance Services No chargeFor 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 No chargeFor 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 TherapyNo charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearBehavioral TherapyNo chargeNoneHabilitative ServicesPhysical TherapyNo charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearRehabilitative ServicesPhysical Therapy No charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearCardiac Rehabilitation ServicesNo charge36 visits per benefit yearPulmonary RehabilitationNo charge20 visits per benefit yearChiropractic ServicesNo chargeManipulation therapy-12 visits per benefit yearLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver Zero3OH-EXCM-1021BZCovered 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 No chargePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health No chargePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice CareNo chargePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducationNo chargeNoneEquipment No chargeNoneSuppliesNo chargeNoneMedical Supplies, Durable Medical Equipment, and AppliancesNo chargeMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)No chargeTier 2 (Preferred)No chargeTier 3 (Non-Preferred)No chargeTier 4 (Specialty Preferred)No chargeTier 5 (Specialty Non-Preferred)No chargeMail Order May require prior authorizationTier 0 (Preventive)No chargeUp to a 90-day supplyTier 1 (Low Cost)No chargeUp to a 90-day supplyTier 2 (Preferred)No chargeUp to a 90-day supplyTier 3 (Non-Preferred)No chargeUp to a 90-day supplyTier 4 (Specialty Preferred)No chargeUp to a 30-day supplyTier 5 (Specialty Non-Preferred)No chargeUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$25 copayNoneSpecialist Care$60 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Standard SilverLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-BS Silver1OH-EXCM-1019HighlightsAnnual Deductible* Individual: $5,900 Family: $11,800Coinsurance20%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,800Family: $13,600* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $5,900 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 $11,800 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 $5,900 up to the family maximum of $11,800. 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 $6,800. 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.BPlan 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)-BS Silver2OH-EXCM-1019BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 20% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology$200 copay after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)$250 copay after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic$200 copay after deductiblePrior authorization requiredInpatient Services Facility/Physician$500 copay after deductiblePrior authorization requiredSkilled Nursing Facility$500 copay after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician20% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $60 copayNoneInpatient Services$500 copay after deductiblePrior authorization requiredOutpatient Services20% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 20% 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 $500 copay 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 Therapy$25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearBehavioral Therapy$25 copayNoneHabilitative ServicesPhysical Therapy$25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearRehabilitative ServicesPhysical Therapy $25 copay20 visits per benefit yearOccupational Therapy$25 copay20 visits per benefit yearSpeech Therapy20% coinsurance after deductible20 visits per benefit yearCardiac Rehabilitation Services20% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation20% coinsurance after deductible20 visits per benefit yearChiropractic Services20% 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)-BS Silver3OH-EXCM-1019BCovered 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 20% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 20% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care20% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation20% coinsurance after deductibleNoneEquipment 20% coinsurance after deductibleNoneSupplies20% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances20% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$30 copayTier 2 (Preferred)$60 copayTier 3 (Non-Preferred)20% coinsurance after deductibleTier 4 (Specialty Preferred)20% 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)$75 copayUp to a 90-day supplyTier 2 (Preferred)$150 copayUp to a 90-day supplyTier 3 (Non-Preferred)20% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)20% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$10 copayNoneSpecialist Care$45 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Gold LimitedLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-B Gold Limited1OH-EXCM-1018HighlightsAnnual Deductible* Individual: $2,000 Family: $4,000Coinsurance20%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,500Family: $13,000* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $2,000 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 $4,000 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 $2,000 up to the family maximum of $4,000. 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 $6,500. 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.BNPlan 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)-B Gold Limited2OH-EXCM-1018BNCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 20% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology20% coinsurance after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)20% coinsurance after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic20% coinsurance after deductiblePrior authorization requiredInpatient Services Facility/Physician20% coinsurance after deductiblePrior authorization requiredSkilled Nursing Facility20% coinsurance after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician20% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $45 copayNoneInpatient Services20% coinsurance after deductiblePrior authorization requiredOutpatient Services20% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 20% 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 20% 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 Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearBehavioral Therapy$10 copayNoneHabilitative ServicesPhysical Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearRehabilitative ServicesPhysical Therapy $10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearCardiac Rehabilitation Services20% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation20% coinsurance after deductible20 visits per benefit yearChiropractic Services20% 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)-B Gold Limited3OH-EXCM-1018BNCovered 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 20% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 20% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care20% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation20% coinsurance after deductibleNoneEquipment 20% coinsurance after deductibleNoneSupplies20% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances20% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$15 copayTier 2 (Preferred)$50 copayTier 3 (Non-Preferred)40% coinsurance after deductibleTier 4 (Specialty Preferred)40% 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)$37.50 copayUp to a 90-day supplyTier 2 (Preferred)$125 copayUp to a 90-day supplyTier 3 (Non-Preferred)40% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)40% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary CareNo chargeNoneSpecialist CareNo chargeNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace Gold ZeroLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-B Gold Zero1OH-EXCM-1017HighlightsAnnual Deductible* Individual: $0 Family: $0Coinsurance0%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $0Family: $0* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $0 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 $0 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 $0 up to the family maximum of $0. 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 $0. 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.BZPlan 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)-B Gold Zero2OH-EXCM-1017BZCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab No chargeMay require prior authorizationX-Ray/RadiologyNo chargeMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)No chargePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnosticNo chargePrior authorization requiredInpatient Services Facility/PhysicianNo chargePrior authorization requiredSkilled Nursing FacilityNo chargePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/PhysicianNo chargeMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care No chargeNoneInpatient ServicesNo chargePrior authorization requiredOutpatient ServicesNo chargeMay require prior authorizationUrgent Care No chargeNoneAmbulance Services No chargeFor 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 No chargeFor 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 TherapyNo charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearBehavioral TherapyNo chargeNoneHabilitative ServicesPhysical TherapyNo charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearRehabilitative ServicesPhysical Therapy No charge20 visits per benefit yearOccupational TherapyNo charge20 visits per benefit yearSpeech TherapyNo charge20 visits per benefit yearCardiac Rehabilitation ServicesNo charge36 visits per benefit yearPulmonary RehabilitationNo charge20 visits per benefit yearChiropractic ServicesNo chargeManipulation therapy-12 visits per benefit yearLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-B Gold Zero3OH-EXCM-1017BZCovered 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 No chargePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health No chargePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice CareNo chargePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducationNo chargeNoneEquipment No chargeNoneSuppliesNo chargeNoneMedical Supplies, Durable Medical Equipment, and AppliancesNo chargeMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)No chargeTier 2 (Preferred)No chargeTier 3 (Non-Preferred)No chargeTier 4 (Specialty Preferred)No chargeTier 5 (Specialty Non-Preferred)No chargeMail Order May require prior authorizationTier 0 (Preventive)No chargeUp to a 90-day supplyTier 1 (Low Cost)No chargeUp to a 90-day supplyTier 2 (Preferred)No chargeUp to a 90-day supplyTier 3 (Non-Preferred)No chargeUp to a 90-day supplyTier 4 (Specialty Preferred)No chargeUp to a 30-day supplyTier 5 (Specialty Non-Preferred)No chargeUp to a 30-day supply
Covered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Office Visits (includes retail clinics)Primary Care$10 copayNoneSpecialist Care$45 copayNonePreventive CareAs defined by federal lawNo chargeNone2020 Schedule of Benefits Plan Name: CareSource Marketplace GoldLearn more about CareSource and all our plan options at www.caresource.com/marketplace.SCH-OH001(2020)-B Gold1OH-EXCM-1015HighlightsAnnual Deductible* Individual: $2,000 Family: $4,000Coinsurance20%Annual Out-of-Pocket Maximum** (includes deductible, coinsurance, and copays)Individual: $6,500Family: $13,000* See Section 13: Evidence of Coverage Glossary for the definition of annual deductible. For individual coverage, you are responsible for paying the first $2,000 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 $4,000 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 $2,000 up to the family maximum of $4,000. 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 $6,500. 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.BPlan 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)-B Gold2OH-EXCM-1015BCovered ServiceYou Pay (Network Providers Only)Limit (If Applicable)Diagnostic Services Lab 20% coinsurance after deductibleMay require prior authorizationX-Ray/Radiology20% coinsurance after deductibleMay require prior authorizationAdvanced Imaging (PET, MRI, MRA, CT, SPECT)20% coinsurance after deductiblePrior authorization requiredMammograms (outpatient)PreventiveNo chargeNoneDiagnostic20% coinsurance after deductiblePrior authorization requiredInpatient Services Facility/Physician20% coinsurance after deductiblePrior authorization requiredSkilled Nursing Facility20% coinsurance after deductiblePrior authorization required 90 day limit per benefit yearOutpatient Services Facility/Physician20% coinsurance after deductibleMay require prior authorizationMaternity ServicesPrenatal Visit, Office Visits, and Postpartum Care $45 copayNoneInpatient Services20% coinsurance after deductiblePrior authorization requiredOutpatient Services20% coinsurance after deductibleMay require prior authorizationUrgent Care $75 copayNoneAmbulance Services 20% 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 20% 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 Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearBehavioral Therapy$10 copayNoneHabilitative ServicesPhysical Therapy$10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearRehabilitative ServicesPhysical Therapy $10 copay20 visits per benefit yearOccupational Therapy$10 copay20 visits per benefit yearSpeech Therapy$10 copay20 visits per benefit yearCardiac Rehabilitation Services20% coinsurance after deductible36 visits per benefit yearPulmonary Rehabilitation20% coinsurance after deductible20 visits per benefit yearChiropractic Services20% 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)-B Gold3OH-EXCM-1015BCovered 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 20% coinsurance after deductiblePrior authorization required100 visits per benefit year A visit equals 8 hoursHome Health 20% coinsurance after deductiblePrior authorization required100 combined visits per benefit year A visit equals at least 4 hoursHospice Care20% coinsurance after deductiblePrior authorization is required for inpatient, respite, or continuous care levels of care.Diabetic ServicesEducation20% coinsurance after deductibleNoneEquipment 20% coinsurance after deductibleNoneSupplies20% coinsurance after deductibleNoneMedical Supplies, Durable Medical Equipment, and Appliances20% coinsurance after deductibleMay require prior authorizationPrescription DrugsRetail Up to a 30-day supply May require prior authorizationTier 0 (Preventive)No chargeTier 1 (Low Cost)$15 copayTier 2 (Preferred)$50 copayTier 3 (Non-Preferred)40% coinsurance after deductibleTier 4 (Specialty Preferred)40% 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)$37.50 copayUp to a 90-day supplyTier 2 (Preferred)$125 copayUp to a 90-day supplyTier 3 (Non-Preferred)40% coinsurance after deductibleUp to a 90-day supplyTier 4 (Specialty Preferred)40% coinsurance after deductibleUp to a 30-day supplyTier 5 (Specialty Non-Preferred)50% coinsurance after deductibleUp to a 30-day supply
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