SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency care. Deductibles, Coinsurance and Copayments that make up Your Out-of- Pocket Limit accumulate on a calendar year ending on December 31 of each year. OFFICE VISITS Primary Care Office Visits (or Home Visits) Specialist Office Visits (or Home Visits) Limits MBR 17.097 1
PREVENTIVE CARE Well Child Visits and Immunizations* Limits Adult Annual Physical Examinations* Adult Immunizations* Routine Gynecological /Well Woman Exams* Mammograms, Screening and Diagnostic Imaging for the Detection of Breast Cancer Sterilization Procedures for Women* Vasectomy See Surgical Cost- Sharing Bone Density Testing* Screening for Prostate Cancer Performed in PCP Office Performed in Specialist Office MBR 17.097 2
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 Pre-Hospital Emergency Medical (Ambulance ) Use for appropriate service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology ; Laboratory Procedures and Diagnostic Testing) Limits Non-Emergency Ambulance Emergency Department $150 Copayment $150 Copayment Copayment waived if Hospital admission Urgent Care Center PROFESSIONAL SERVICES and OUTPATIENT CARE Advanced Imaging Limits Performed in a Freestanding Radiology Facility MBR 17.097 3
Performed as Outpatient Hospital Allergy Testing and Treatment Performed in a PCP Office Ambulatory Surgical Center Facility Fee Anesthesia (all settings) Autologous Blood Banking Cardiac and Pulmonary Rehabilitation Performed as Outpatient Hospital Performed as Inpatient Hospital Included as part of inpatient Hospital service Included as part of inpatient Hospital service Cost- MBR 17.097 4
Chemotherapy Performed in a PCP Office Sharing Preauthorization required Performed as Outpatient Hospital Chiropractic Clinical Trials Diagnostic Testing Performed in a PCP Office Use for appropriate service Use for appropriate service Preauthorization required Performed as Outpatient Hospital Dialysis MBR 17.097 5
Performed in a PCP Office Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year Performed in a Freestanding Center Performed as Outpatient Hospital Habilitation (Physical Therapy, Occupational Therapy or Speech Therapy) 20 visits per Plan Year combined therapies Home Health Care Infertility Infusion Therapy Performed in a PCP Office Use for appropriate service (Office Visit; Diagnostic Radiology ; Surgery; Laboratory & Diagnostic Procedures) 40 visits per Plan Year Performed in Specialist Office MBR 17.097 6
Performed as Outpatient Hospital Home Infusion Therapy Inpatient Medical Visits Interruption of Pregnancy Home infusion counts toward home health care visit limits Medically Necessary Abortions n Unlimited Elective Abortions Laboratory Procedures Performed in a PCP Office One (1) procedure per Plan Year Performed in a Freestanding Laboratory Facility Performed as Outpatient Hospital MBR 17.097 7
Maternity and Newborn Care Prenatal Care Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Prenatal Care that is not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Use for appropriate service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology ; Laboratory Procedures and Diagnostic Testing) Use for appropriate service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology ; Laboratory Procedures and Diagnostic Testing) Inpatient Hospital Physician and Midwife for Delivery One (1) home care visit is Covered at no Cost- Sharing if mother is discharged from Hospital early Breastfeeding Support, Counseling and Supplies, Including Breast Pumps Covered for duration of breast feeding Postnatal Care Included in Physician and Midwife for Delivery Outpatient Hospital Surgery Facility Charge Preauthorization required MBR 17.097 8
Preadmission Testing Prescription Drugs Administered in Office or Outpatient Facilities Performed in a PCP Office Included as part of the PCP office visit Performed in Specialist Office Included as part of the Specialist office visit Cost- Sharing Performed in Outpatient Facilities Diagnostic Radiology Performed in a PCP Office Performed in a Freestanding Radiology Facility Performed as Outpatient Hospital Therapeutic Radiology MBR 17.097 9
Performed in a Freestanding Radiology Facility Performed as Outpatient Hospital Rehabilitation (Physical Therapy, Occupational Therapy or Speech Therapy) Second Opinions on the Diagnosis of Cancer, Surgery and Other Surgical (including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive and Corrective Surgery; and Transplants) Second opinions on diagnosis of cancer are Covered at participating for nonparticipating Specialist when a Referral is obtained. Preauthorization required 20 visits per Plan Year combined therapies Speech and physical therapy are only Covered following a Hospital stay or surgery Inpatient Hospital Surgery All transplants must be performed at MBR 17.097 10
Outpatient Hospital Surgery designated Facilities Surgery Performed at an Ambulatory Surgical Center Office Surgery ADDITIONAL SERVICES, EQUIPMENT and DEVICES ABA Treatment for Autism Spectrum Disorder Assistive Communication Devices for Autism Spectrum Disorder Diabetic Equipment, Supplies and Self- Management Education Limits Diabetic Equipment, Supplies and Insulin (30-day supply) Diabetic Education Durable Medical Equipment and Braces External Hearing Aids Single purchase once every three (3) years MBR 17.097 11
Cochlear Implants Hospice Care One (1) per ear per time Covered Inpatient Outpatient Medical Supplies Prosthetic Devices 210 days per Plan Year Five (5) visits for family bereavement counseling External One (1) prosthetic device, per limb, per lifetime with coverage for repairs and replacements Internal Included as part of inpatient Hospital Unlimited; INPATIENT SERVICES and FACILITIES Inpatient Hospital for a Continuous Confinement (including an Inpatient Stay for Mastectomy Care, Cardiac and Pulmonary Rehabilitation, and End of Life Care) Limits MBR 17.097 12
Observation Stay Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) Inpatient Habilitation (Physical, Speech and Occupational Therapy) Inpatient Rehabilitation (Physical, Speech and Occupational Therapy) MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care including Residential Treatment (for a continuous confinement when in a Hospital) 200 days per Plan Year 20 visits per Plan Year combined therapies 20 visits per Plan Year combined therapies Limits Outpatient Mental Health Care (including Partial Hospitalization and Intensive Outpatient Program ) Inpatient Substance Use including Residential Treatment (for a continuous confinement when in a Hospital) Outpatient Substance Use (including Partial Hospitalization, Intensive Outpatient Program, and Medication Assisted Treatment) Unlimited; Up to 20 visits per Plan Year may be used for family counseling MBR 17.097 13
All in-network Preauthorization requests are the responsibility of Your. You will not be penalized for a Participating Provider s failure to obtain a required Preauthorization. However, if under the Contract, You will be responsible for the full cost of the services. MBR 17.097 14