| wdt_ID | wdt_created_by | wdt_created_at | wdt_last_edited_by | wdt_last_edited_at | Plan Name | Year | Line of Business | Web ID | Plan Type | Actuarial Benefit Value | Plan Description | Plan Notes | Best For | Covered California | Annual Medical Deductible | Annual Drug Deductible | Maximum Out of Pocket | Lifetime Maximums | Preventive Care / Screening / Immunization | Family Planning (Consultation and Contraceptive Services) | Preconception and Prenatal Visits | Diabetes Care Management | Diabetes Education | Primary Care Visit to Treat an Injury or Illness | Specialist Visit | Acupuncture | Physical Therapy | Occupational Therapy | Allergy Visit (Testing and Treatment) | Other Practitioner Office Visit | Laboratory Tests | X-Rays | Imaging (CT/PET Scans, MRIs) | Outpatient Surgery Facility Fee | Outpatient Physician/Surgeon Fees | Outpatient Visit | Termination of Pregnancy | Inpatient Facility Fee | Inpatient Physician/Surgeon Fees | Delivery and All Inpatient Services (Hospital Services) | Delivery and All Inpatient Services (Professional Services) | Emergency Room Services | Emergency Room Physician Fee | Urgent Care | Medical Transportation (Including Emergency and Non-emergency) | Tier 1: Generic Drugs (30-Day Supply) | Tier 1: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 2: Preferred Brand Drugs (30-Day Supply) | Tier 2: Preferred Brand (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | Tier 3: Non-Preferred Brand (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 4: Specialty Drugs (30-Day Supply) | Tier 4: Specialty Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Medical Supplies | Prosthetic Devices | Durable Medical Equipment | Mental/Behavioral Health Outpatient Office Visits | Mental/Behavioral Health Other Outpatient Items and Services | Mental/Behavioral Health Inpatient Facility Fee | Mental/Behavioral Health Inpatient Professional Fee | Substance Use Disorder Outpatient Office Visits | Substance Use Disorder Other Outpatient items and Services | Substance Use Disorder Inpatient Facility Services | Substance Use Disorder Inpatient Professional Fee | Home Health Care | Infusion Services | Rehabilitation Services | Habilitation Services | Skilled Nursing Care | Hospice Services | Pre-Hospice Consultation | Inpatient Respite Care | Annual Eye Exam | Annual Eyewear - Lenses and Frames | Contact Lenses in Lieu of Glasses | Dental Check-Up | Infertility (Optional Rider) | Infertility Imaging Tests | Infertility Drugs | Infertility Laboratory Tests | Infertility Specialist Office Visit | Artificial Insemination (AI) | Gamete intrafallopian transfer (GIFT) | Coverage Start Date | Coverage End Date | Rx HQ Code | Legacy Rx HQ Code | Rx Benefit Code Root | Legacy Rx Benefit Code Root | Rx Notes |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | imLana | 11/09/2025 09:01 AM | imLana | 11/09/2025 09:01 AM | Platinum 90 HMO | 2025 | Individual and Family | 2025-platinum-90-hmo-ifp | HMO | 91.60% | Provides comprehensive coverage. On average, plan pays 90% of medical expenses. | Individuals & families who utilize medical services regularly. | Yes | None | None | Individual $4,500 / Family $9,000 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $15 Copay | $30 Copay | $15 Copay | $15 Copay | $15 Copay | $30 Copay | $15 Copay | $15 Copay | $30 Copay | $75 Copay | $75 Copay | $20 Copay | 10% Coinsurance | $0 Copay | $225 Copay/Day (Up to the first 5 Days) | $0 Copay | $225 Copay/Day (Up to the first 5 Days) | $0 Copay | $150 Copay | $0 Copay | $15 Copay | $150 Copay | $7 Copay | $14 Copay | $16 Copay | $32 Copay | $25 Copay | $50 Copay | 10% Coinsurance, up to $250 Copay | Not Covered | 10% Coinsurance | 10% Coinsurance | 10% Coinsurance | $15 Copay | $15 Copay | $225 Copay/Day (Up to the first 5 Days) | $0 Copay | $15 Copay | $15 Copay | $225 Copay/Day (Up to the first 5 Days) | $0 Copay | $20 Copay | $20 Copay | $15 Copay | $15 Copay | $125 Copay/Day (Up to the first 5 Days) | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | |||||||||
| 2 | imLana | 11/09/2025 09:01 AM | imLana | 11/09/2025 09:01 AM | Gold 80 HMO | 2025 | Individual and Family | 2025-gold-80-hmo-ifp | HMO | 81.60% | Comprehensive plan with more affordable premiums than Platinum level. On average, plan pays 80% of medical expenses. | Individuals & families with moderate medical needs. | Yes | None | None | Individual $8,700 / Family $17,400 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $35 Copay | $65 Copay | $35 Copay | $35 Copay | $35 Copay | $65 Copay | $35 Copay | $40 Copay | $75 Copay | $75 Copay | $130 Copay | $60 Copay | 20% Coinsurance | $0 Copay | $350 Copay/Day (Up to the first 5 Days) | $0 Copay | $350 Copay/Day (Up to the first 5 Days) | $0 Copay | $330 Copay | $0 Copay | $35 Copay | $250 Copay | $15 Copay | $30 Copay | $60 Copay | $120 Copay | $85 Copay | $170 Copay | 20% Coinsurance, up to $250 Copay | Not Covered | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | $35 Copay | $35 Copay | $350 Copay/Day (Up to the first 5 Days) | $0 Copay | $35 Copay | $35 Copay | $350 Copay/Day (Up to the first 5 Days) | $0 Copay | $30 Copay | $30 Copay | $35 Copay | $35 Copay | $150 Copay/Day (Up to the first 5 Days) | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | |||||||||
| 3 | imLana | 11/09/2025 09:01 AM | imLana | 15/09/2025 08:51 AM | Silver 70 HMO | 2025 | Individual and Family | 2025-silver-70-hmo-ifp | HMO | 71.60% | Affordable coverage plan. On average, plan pays 70% of medical expenses. More affordable options available to people with subsidies. | Individuals & families who can afford periodic out-of-pocket costs. | Yes | Individual $5,400 / Family $10,800 | Individual $50 / Family $100 | Individual $8,700 / Family $17,400 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $50 Copay | $90 Copay | $50 Copay | $50 Copay | $50 Copay | $90 Copay | $50 Copay | $50 Copay | $95 Copay | $325 Copay | 30% Coinsurance | 30% Coinsurance | 30% Coinsurance | 0% Coinsurance | After Deductible, 30% Coinsurance | 30% Coinsurance | After Deductible, 30% Coinsurance | 30% Coinsurance | $400 Copay | $0 Copay | $50 Copay | $250 Copay | $18 Copay | $36 Copay | After Deductible, $60 Copay | After Deductible, $120 Copay | After Deductible, $90 Copay | After Deductible, $180 Copay | After Drug Deductible, 20% Coinsurance, up to $250 Copay | Not Covered | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | $50 Copay | $50 Copay | After Deductible, 30% Coinsurance | 30% Coinsurance | $50 Copay | $50 Copay | After Deductible, 30% Coinsurance | 30% Coinsurance | $45 Copay | $45 Copay | $50 Copay | $50 Copay | After Deductible, 30% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | SFC02 | ||||||||
| 4 | imLana | 11/09/2025 09:01 AM | imLana | 12/09/2025 12:13 PM | Bronze 60 HMO | 2025 | Individual and Family | 2025-bronze-60-hmo-ifp | HMO | 63.60% | Low premium plan. On average, plan pays 60% of medical expenses. | Bronze plans will waive the deductible for the first 3 non-preventive visits for any combination of the following services: primary care office visits, specialist office visits, urgent care visits, or Mental Health / Substance Use Disorder outpatient offi | Individuals & families with minimal medical needs. | Yes | Individual $5,800 / Family $11,600 | Individual $450 / Family $900 | Individual $8,850 / Family $17,700 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $60 Copay | $95 Copay for the first 3 non-preventive visits, then Deductible Applies | $60 Copay | $60 Copay | $60 Copay | $95 Copay for the first 3 non-preventive visits, then Deductible Applies | $60 Copay | $40 Copay | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | $0 Copay | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | $0 Copay | $60 Copay | After Deductible, 40% Coinsurance | $19 Copay | $38 Copay | After Drug Deductible, 40% Coinsurance, up to $500 Copay | After Drug Deductible, 40% Coinsurance, up to $1,500 Copay | After Drug Deductible, 40% Coinsurance, up to $500 Copay | After Drug Deductible, 40% Coinsurance, up to $1,500 Copay | After Drug Deductible, 40% Coinsurance, up to $500 Copay | Not Covered | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | $60 Copay | $60 Copay | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | $60 Copay | $60 Copay | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | After Deductible, 40% Coinsurance | $60 Copay | $60 Copay | After Deductible, 40% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | ||||||||
| 5 | imLana | 11/09/2025 09:01 AM | imLana | 29/09/2025 11:54 AM | Bronze 60 HDHP HMO | 2025 | Individual and Family | 2025-bronze-60-hdhp-hmo-ifp | HDHP | 64.90% | Low premium plan. On average, plan pays 60% of medical expenses.*Health Savings Account eligible High Deductible Health Plan. | Bronze plans will waive the deductible for the first 3 non-preventive visits for any combination of the following services: primary care office visits, specialist office visits, urgent care visits, or Mental Health / Substance Use Disorder outpatient offi | Individuals & families with minimal medical needs and plans to fund use an HSA | Yes | Individual $6,650 / Family $13,300 (Combined Medical/Drug Deductible) | Individual $6,650 / Family $13,300 (Combined Medical/Drug Deductible) | Individual $6,650 / Family $13,300 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | $0 Copay | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | Not Covered | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | ||||||||
| 6 | imLana | 11/09/2025 09:01 AM | imLana | 26/09/2025 12:12 PM | American Indian / Alaskan Native $0 Cost Sharing | 2025 | Individual and Family | 2025-american-indian-alaskan-native-hmo-ifp | HMO | Yes | None | None | None | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | SFC02 | SFC02 | ||||||||||
| 7 | imLana | 11/09/2025 09:01 AM | imLana | 29/09/2025 11:55 AM | Minimum Coverage HMO | 2025 | Individual and Family | 2025-minimum-coverage-hmo-ifp | HMO | Lowest premium plan and mostly protects from worst-case scenarios. For adults younger than 30 years old only. | Minimum Coverage will waive the deductible for the first 3 non-preventive visits for any combination for the following services: Primary care visits, urgent care, mental health/substance use disorder outpatient office visits | Individuals or a Young Family who want a little coverage for a modest premium. | Yes | Individual $9,200 / Family $18,400 (Combined Medical/Drug Deductible) | Individual $9,200 / Family $18,400 (Combined Medical/Drug Deductible) | Individual $9,200 / Family $18,400 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | After Deductible, 0% Coinsurance | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | $0 Copay | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | 0% Coinsurance | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | After Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | After Combined Medical/Drug Deductible, 0% Coinsurance | Not Covered | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | 0% Coinsurance for the first 3 non-preventive visits, then Deductible Applies | 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | 0% Coinsurance | After Deductible, 0% Coinsurance | After Deductible, 0% Coinsurance | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | |||||||||
| 8 | imLana | 11/09/2025 09:01 AM | imLana | 15/09/2025 08:48 AM | Silver 94 HMO | 2025 | Individual and Family | 2025-silver-94-hmo-ifp | HMO | 95.10% | Subsidized plan that pays 94% of medical expenses. | Individuals & Families that qualify for a subsidy based on income. | Yes | None | None | Individual $1,150 / Family $2,300 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $5 Copay | $8 Copay | $5 Copay | $5 Copay | $5 Copay | $8 Copay | $5 Copay | $8 Copay | $8 Copay | $50 Copay | 10% Coinsurance | 10% Coinsurance | 10% Coinsurance | $0 Copay | 10% Coinsurance | 10% Coinsurance | 10% Coinsurance | 10% Coinsurance | $50 Copay | $0 Copay | $5 Copay | $30 Copay | $3 Copay | $6 Copay | $10 Copay | $20 Copay | $15 Copay | $30 Copay | 10% Coinsurance, up to $150 Copay | Not Covered | 10% Coinsurance | 10% Coinsurance | 10% Coinsurance | $5 Copay | $5 Copay | 10% Coinsurance | 10% Coinsurance | $5 Copay | $5 Copay | 10% Coinsurance | 10% Coinsurance | $3 Copay | $3 Copay | $5 Copay | $5 Copay | 10% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | SFC02 | ||||||||
| 9 | imLana | 11/09/2025 09:01 AM | imLana | 15/09/2025 08:49 AM | Silver 87 HMO | 2025 | Individual and Family | 2025-silver-87-hmo-ifp | HMO | 88.90% | Subsidized plan that pays 87% of medical expenses. | Individuals & Families that qualify for a subsidy based on income. | Yes | None | None | Individual $3,000 / Family $6,000 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $15 Copay | $25 Copay | $15 Copay | $15 Copay | $15 Copay | $25 Copay | $15 Copay | $20 Copay | $40 Copay | $100 Copay | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | $0 Copay | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | $150 Copay | $0 Copay | $15 Copay | $75 Copay | $5 Copay | $10 Copay | $25 Copay | $50 Copay | $45 Copay | $90 Copay | 15% Coinsurance, up to $150 Copay | Not Covered | 15% Coinsurance | 15% Coinsurance | 15% Coinsurance | $15 Copay | $15 Copay | 25% Coinsurance | 25% Coinsurance | $15 Copay | $15 Copay | 25% Coinsurance | 25% Coinsurance | $15 Copay | $15 Copay | $15 Copay | $15 Copay | 20% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | SFC02 | ||||||||
| 10 | imLana | 11/09/2025 09:01 AM | imLana | 15/09/2025 08:50 AM | Silver 73 HMO | 2025 | Individual and Family | 2025-silver-73-hmo-ifp | HMO | 79.20% | Subsidized plan that pays 73% of medical expenses. | Individuals & Families that qualify for a subsidy based on income. | Yes | None | None | Individual $6,100 / Family $12,200 | None | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $35 Copay | $85 Copay | $35 Copay | $35 Copay | $35 Copay | $85 Copay | $35 Copay | $50 Copay | $95 Copay | $325 Copay | 30% Coinsurance | 30% Coinsurance | 30% Coinsurance | $0 Copay | 30% Coinsurance | 30% Coinsurance | 30% Coinsurance | 30% Coinsurance | $350 Copay | $0 Copay | $35 Copay | $250 Copay | $15 Copay | $30 Copay | $55 Copay | $110 Copay | $85 Copay | $170 Copay | 20% Coinsurance, up to $250 Copay | Not Covered | 20% Coinsurance | 20% Coinsurance | 20% Coinsurance | $35 Copay | $35 Copay | 30% Coinsurance | 30% Coinsurance | $35 Copay | $35 Copay | 30% Coinsurance | 30% Coinsurance | $40 Copay | $40 Copay | $35 Copay | $35 Copay | 30% Coinsurance | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | $0 Copay | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | SFC02 | ||||||||
| Plan Name | Year | Line of Business | Web ID | Plan Type | Actuarial Benefit Value | Plan Description | Plan Notes | Best For | Covered California | Annual Medical Deductible | Annual Drug Deductible | Maximum Out of Pocket | Lifetime Maximums | Preventive Care / Screening / Immunization | Family Planning (Consultation and Contraceptive Services) | Preconception and Prenatal Visits | Diabetes Care Management | Diabetes Education | Primary Care Visit to Treat an Injury or Illness | Specialist Visit | Acupuncture | Physical Therapy | Occupational Therapy | Allergy Visit (Testing and Treatment) | Other Practitioner Office Visit | Laboratory Tests | X-Rays | Imaging (CT/PET Scans, MRIs) | Outpatient Surgery Facility Fee | Outpatient Physician/Surgeon Fees | Outpatient Visit | Termination of Pregnancy | Inpatient Facility Fee | Inpatient Physician/Surgeon Fees | Delivery and All Inpatient Services (Hospital Services) | Delivery and All Inpatient Services (Professional Services) | Emergency Room Services | Emergency Room Physician Fee | Urgent Care | Medical Transportation (Including Emergency and Non-emergency) | Tier 1: Generic Drugs (30-Day Supply) | Tier 1: Generic Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 2: Preferred Brand Drugs (30-Day Supply) | Tier 2: Preferred Brand (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 3: Non-Preferred Brand Drugs (30-Day Supply) | Tier 3: Non-Preferred Brand (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Tier 4: Specialty Drugs (30-Day Supply) | Tier 4: Specialty Drugs (90-Day Supply) Chinese Hospital Pharmacy, or Mail Order | Medical Supplies | Prosthetic Devices | Durable Medical Equipment | Mental/Behavioral Health Outpatient Office Visits | Mental/Behavioral Health Other Outpatient Items and Services | Mental/Behavioral Health Inpatient Facility Fee | Mental/Behavioral Health Inpatient Professional Fee | Substance Use Disorder Outpatient Office Visits | Substance Use Disorder Other Outpatient items and Services | Substance Use Disorder Inpatient Facility Services | Substance Use Disorder Inpatient Professional Fee | Home Health Care | Infusion Services | Rehabilitation Services | Habilitation Services | Skilled Nursing Care | Hospice Services | Pre-Hospice Consultation | Inpatient Respite Care | Annual Eye Exam | Annual Eyewear - Lenses and Frames | Contact Lenses in Lieu of Glasses | Dental Check-Up | Infertility (Optional Rider) | Infertility Imaging Tests | Infertility Drugs | Infertility Laboratory Tests | Infertility Specialist Office Visit | Artificial Insemination (AI) | Gamete intrafallopian transfer (GIFT) | Coverage Start Date | Coverage End Date | Rx HQ Code | Legacy Rx HQ Code | Rx Benefit Code Root | Legacy Rx Benefit Code Root | Rx Notes |
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