Plan Brochure - Health Insurance Quotes

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26 Benefit Limitations Individual and Family <strong>Plan</strong> Dollar Limitations on Specific Benefits Benefit Preferred Value Option HSA Uniform Ambulance service Ground to the nearest facility capable of treating medical condition. Air covered when ground ambulance is medically or physically inappropriate. Autism Spectrum Disorder Ages 0-8: $50,000 per calendar year Ages 9-18: $20,000 per calendar year Ages 19+: Subject to plans benefit for severe mental illness Cardiac rehabilitation (phase II) Chemical dependency Inpatient: Five days per calendar year Outpatient: 10 visits per calendar year To help you understand your coverage limitations, the table below provides an overview of dollar and visit limitations on specific benefits by plan.This is not a complete list. Please refer to the complete policy for the plan of your choice for specific information. Contact us directly toll-free at (888) 684- 5585, or by email at montanaindividual@pacificsource.com if you have questions. Ground to the nearest facility capable of treating medical condition. Air covered when ground ambulance is medically or physically inappropriate. Ages 0-8: $50,000 per calendar year Ages 9-18: $20,000 per calendar year Ages 19+: Subject to plans benefit for severe mental illness Ground to the nearest facility capable of treating medical condition. Air covered when ground ambulance is medically or physically inappropriate. Ages 0-8: $50,000 per calendar year Ages 9-18: $20,000 per calendar year Ages 19+: Subject to plans benefit for severe mental illness Ground to the nearest facility capable of treating medical condition. Air covered when ground ambulance is medically or physically inappropriate. Ages 0-8: $50,000 per calendar year Ages 9-18: $20,000 per calendar year Ages 19+: Subject to plans benefit for severe mental illness 36 sessions/lifetime 36 sessions/lifetime 36 sessions/lifetime 36 sessions/lifetime Inpatient: Five days per calendar year Outpatient: 10 visits per calendar year Inpatient: Five days per calendar year Outpatient: 10 visits per calendar year Inpatient: Five days per calendar year Outpatient: 10 visits per calendar year Chiropractic care 10 visits per calendar year 10 visits per calendar year 10 visits per calendar year 10 visits per calendar year Naturopathic care Covered as office visit Covered as office visit Covered as office visit Not covered Dietary/nutritional counseling for anorexia or bulimia Five visits/lifetime Five visits/lifetime Five visits/lifetime Five visits/lifetime Durable medical equipment $2,500 per calendar year $2,500 per calendar year $2,500 per calendar year $1,000 per calendar year Gynecological exams One exam per One exam per One exam per One exam per calendar year calendar year calendar year calendar year Hospice or respite care $10,000/lifetime $10,000/lifetime $10,000/lifetime $10,000/lifetime Outpatient Rehabilitative Services 30 visits per calendar year 30 visits per calendar year 30 visits per calendar year 30 visits per calendar year
If any covered expense listed below is deemed to be an “essential health benefit” by the Secretary of the U.S. Department of <strong>Health</strong> and Human Services, the maximum benefit amount listed below will not apply to that covered expense in accordance with the standards established by the Secretary. Benefit Preferred Value Option HSA Uniform Prescription drug expense Does not accumulate toward out-of-pocket limit. 30-day supply retail, 90-day supply mail order Mental illness Inpatient: 21 days per calendar year Outpatient: 20 visits per calendar year Routine physical exams Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year Does not accumulate toward out-of-pocket limit. 30-day supply retail, 90-day supply mail order Inpatient: 21 days per calendar year Outpatient: 20 visits per calendar year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year Accumulates toward out-ofpocket limit 30-day supply retail, 90-day supply mail order Inpatient: 21 days per calendar year Outpatient: 20 visits per calendar year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year Does not accumulate toward out-of-pocket limit. 30-day supply retail, 90-day supply mail order Inpatient: 21 days per calendar year Outpatient: 20 visits per calendar year Age 22-34: One exam every four years Age 35-59: One exam every two years Age 60+: One exam per year Skilled nursing facility 14 days per calendar year** 14 days per calendar year** 14 days per calendar year** 60 days per calendar year Tobacco use cessation programs (age 15 or older) Two quit attempts/lifetime Two quit attempts/lifetime Two quit attempts/lifetime Two quit attempts/lifetime Vision, routine exams (every two calendar years) Covered Not covered Not covered Not covered Vision, hardware (every two calendar years) $200 hardware, lenses Not covered Not covered Not covered Well child exams At birth: One standard in-hospital exam Age 0-7: As recommended by the child’s pediatrician Age 8-21: One exam per calendar year At birth: One standard in-hospital exam Age 0-7: As recommended by the child’s pediatrician Age 8-21: One exam per calendar year * Service available any time upon referral of a women’s healthcare provider. ** Services may be extended to a maximum of 60 days per year when medically necessary. At birth: One standard in-hospital exam Age 0-7: As recommended by the child’s pediatrician Age 8-21: One exam per calendar year At birth: One standard in-hospital exam Age 0-7: As recommended by the child’s pediatrician Age 8-21: One exam per calendar year 27
Page 1 and 2: Individual and Family Plans Well-Ba
Page 3 and 4: Why We’re the Who We Are Right Fi
Page 5 and 6: Plans At-a-Glance Individual Annual
Page 7 and 8: Value-Added Services Online Tools a
Page 9 and 10: Preferred Annual Benefit Maximum $2
Page 11 and 12: Value Annual Benefit Maximum $2 mil
Page 13 and 14: HSA (HSA-Qualified) Annual Benefit
Page 15 and 16: Uniform Plan Annual Benefit Maximum
Page 17 and 18: Frequently Asked Questions Can my e
Page 19 and 20: To apply or find more information,
Page 21 and 22: Glossary of terms Inpatient care: W
Page 23 and 24: alterations in order to prevent, tr
Page 25: Services otherwise available:These

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