Ohio Essential Health Benefits Benchmark Plan Template Page 1 of 7

Ohio Essential Health Benefits Resource Document for 2015 Plan YearBenefits Covered? Benefit DescriptionQuantitativeLimit onService?LimitQuantityLimit Units"Other" LimitUnits DescriptionMinimumStayExclusionsAdditional ExplanationDoes this benefit haveadditional limitations orrestrictions?Non-PreferredBrand DrugsCoveredNon-Preferred BrandPrescription DrugsNoOver the counter drugs and drugs with over the counter equivalents; Drugs forweight loss; Stop smoking aids; Nutritional and/or dietary supplements; drugsfor the treatment of sexual or erectile dysfunction or inadequacies; fertilitydrugs; human growth hormone for children born small for gestational age;treatment of onchomycosis.Must comply with Regulations at 45 C.F.R. 156.122, providingcoverage for at least the greater of (1) one drug in every USPcategory and class, or (2) the same number of prescription drugs ineach USP category and class as the state's EHB-benchmark plan.Prescription Drug EHB-Benchmark Plan Benefitsby Category and ClassSpecialty Drugs Covered Specialty PrescriptionDrugsNoOver the counter drugs and drugs with over the counter equivalents; Drugs forweight loss; Stop smoking aids; Nutritional and/or dietary supplements; drugsfor the treatment of sexual or erectile dysfunction or inadequacies; fertilitydrugs; human growth hormone for children born small for gestational age;treatment of onchomycosis.Must comply with Regulations at 45 C.F.R. 156.122, providingcoverage for at least the greater of (1) one drug in every USPcategory and class, or (2) the same number of prescription drugs ineach USP category and class as the state's EHB-benchmark plan.Prescription Drug EHB-Benchmark Plan Benefitsby Category and ClassOutpatientRehabilitationServicesCoveredOutpatient RehabilitationServicesYes 116 Other Combined totalvisits/year forall therapies.*Physical Therapy - Non Covered Services include: maintenance therapy to *Includes physical therapy, occupational therapy, speech therapy,delay or minimize muscular deterioration in patients suffering from a chronic pulmonary therapy and cardiac rehabilitation. Separate 20 visitdisease or illness; repetitive exercise to improve movement, maintain strength limits for PT, OT, ST, Pulmonary Rehab; 36 visit limit for Cardiacand increase endurance (including assistance with walking for weak or Rehab.unstable patients); range of motion and passive exercises that are not relatedto restoration of a specific loss of function, but are for maintaining a range ofmotion in paralyzed extremities; general exercise programs; diathermy,ultrasound and heat treatments for pulmonary conditions; diapulse; workhardening.Occupational Therapy - Does not include coverage for diversional,recreational, vocational therapies (e.g., hobbies, arts and crafts). Non CoveredServices include: supplies (looms, ceramic tiles, leather, utensils); therapy toimprove or restore functions that could be expected to improve as the patientresumes normal activities again; general exercises to promote overall fitnessand flexibility; therapy to improve motivation; suction therapy for newborns(feeding machines); soft tissue mobilization (visceral manipulation or visceralsoft tissue manipulation), augmented soft tissue mobilization, myofascial;adaptions to the home such as rampways, door widening, automobileadaptors, kitchen adaptation and other types of similar equipment.Cardiac Rehab - Home programs, on-going conditioning and maintenance arenot covered.Pulmonary Rehab - Pulmonary rehabilitation in the acute Inpatientrehabilitation setting is not a Covered Service.General Exclusions - Non-Covered Services for physical medicine andrehabilitation include, but are not limited to: admission to a Hospital mainly forphysical therapy; long term rehabilitation in an Inpatient setting.Page 7 of 12