COST-SHARING Deductible Individual Family Prescription Drug Deductible Individual Family Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) Specialist Visits (or Home Visits PREVENTIVE CARE Well Child Visits and Immunizations* MVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange Participating Cost-Share $0 $0 $0 $0 $6,350 $12,700 except as required for Emergency Care and Urgent Care. Adult Annual Physical Examinations* Adult Immunizations* Routine Gynecological Services/Well Woman Exams* Mammography Screenings* Sterilization Procedures for Women* 1
Vasectomy Bone Density Testing* Screening for Prostate Cancer All other preventive services required by USPSTF and HRSA. *When preventive services are not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA. EMERGENCY CARE Use Cost for Appropriate Service (Primary Care Visit; Specialist Visit; Diagnostic Radiology Services; Laboratory Procedures & Diagnostic Testing) Pre-Hospital Emergency Medical Services (Ambulance Services) $300 Copayment $300 Copayment Non-Emergency Ambulance Services $300 Copayment $300 Copayment Emergency Department Copayment waived if Hospital $300 Copayment $300 Copayment admission. Urgent Care Center PROFESSIONAL SERVICES AND OUTPATIENT CARE Acupuncture Advanced Imaging Services Performed in a Freestanding Radiology Facility or Setting Allergy Testing & Treatment Performed in a PCP $150 Copayment $150 Copayment 12 visits per Plan Performed in a Specialist Ambulatory Surgical Center Facility Fee $300 Copayment 2
Anesthesia Services (all settings Autologous Blood Banking Cardiac & Pulmonary Rehabilitation Performed in a Specialist See Benefits For See Benefits For Performed as Inpatient Chemotherapy Performed in a PCP Included as part of inpatient Hospital service Performed in a Specialist Chiropractic Services Clinical Trials Diagnostic Testing Performed in a PCP Use for Appropriate Service Performed in a Specialist Dialysis Performed in a PCP Performed in a Freestanding Center or Specialist Setting Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) Dialysis Performed by Non-Participating Providers is Limited to 10 Visits Per Calendar 54 visits per condition, per lifetime combined therapies 3
Home Health Care Infertility Services Infusion Therapy Performed in a PCP Use Cost for Appropriate Service ( Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) 60 Visits per Plan Performed in Specialist Home Infusion Therapy Inpatient Medical Visits Laboratory Procedures Performed in a PCP Home Infusion counts towards Home Health Care Visit Performed in a Freestanding Laboratory Facility or Specialist Maternity & Newborn Care Prenatal Care Inpatient and Birthing Center Physician and Midwife Services for Delivery Covered In Full $500 Copayment per admission 1 Home Care Visit is Covered at no Cost- if mother is discharged from Hospital early Breast Pump Postnatal Care Covered in Full Included as part of the surgeon s cost share for delivery. Covered for duration of breast feeding 4
Outpatient Hospital Surgery Facility Charge $300 Copayment Preadmission Testing Diagnostic Radiology Services Performed in a PCP Performed in a Freestanding Radiology Facility or Specialist Therapeutic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) Second Opinions on the Diagnosis of Cancer, Surgery & Other $150 Copayment $150 Copayment 54 visits per condition, per lifetime combined therapies. Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) Inpatient Hospital Surgery Outpatient Hospital Surgery All Transplants Must be Performed at Designated Facilities Surgery Performed at an Ambulatory Surgical Center Specialist Surgery PCP Surgery 5
ADDITIONAL SERVICES, EQUIPMENT & DEVICES ABA Treatment for Autism Spectrum Disorder Assistive Communication Devices for Autism Spectrum Disorder Diabetic Equipment, Supplies & Self-Management Education Diabetic Equipment, Supplies and Insulin (30-Day Supply) 680 Hours Per Plan Diabetic Education Durable Medical Equipment & Braces External Hearing Aid Cochlear Implants Hospice Care Inpatient $500 Copayment Outpatient Medical Supplies Prosthetic Devices External Internal Out of Service Area INPATIENT SERVICES & FACILITIES Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) Use Cost for Appropriate Service Up to $1000 in out of service area covered benefits per Dependent Child per plan year. $500 Copayment Single Purchase Once Every 3 s One Per Ear Per Time Covered 210 Days per Plan 5 Visits for Family Bereavement Counseling One prosthetic device, per limb, per lifetime Unlimited 6
Observation Stay $300 Copayment $300 Copayment Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) $500 Copayment 200 Days Per Plan Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care (for a continuous confinement when in a Hospital) Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) Inpatient Substance Use Services (for a continuous confinement when in a Hospital) Outpatient Substance Use Services PRESCRIPTION DRUGS Retail Pharmacy 30 Day Supply Tier 1 $500 Copayment $500 Copayment $500 Copayment $5 Copayment 60 Consecutive Days Per Condition, Per Lifetime Unlimited; Up to 20 Visits a Calendar May Be Used For Family Counseling Tier 2 $45 Copayment Tier 3 Enteral Formula 30 Day Supply Tier 1 Tier 2 $5 Copayment $45 Copayment Mail Order Not Available Tier 3 7
WELLNESS BENEFITS Gym Reimbursement PEDIATRIC VISION CARE Pediatric Vision Care Exams Lenses & Frames Up to $125 reimbursement per contract for gym and fitness club membership, youth sports and fitness fees or healthy weight support. One Exam Per 12- Month Period; One Prescribed Standard Lenses & Frames in a 12-Month Period Contact Lenses 8