Master Plan Benefits Table

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
325 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Platinum 90 HMO 2023 Individual and Family 2023-platinum-90-hmo-ifp HMO 0.898 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 $100 Copay $25 Copay 10% Coinsurance $100 Copay $250 Copay/Day (Up to the first 5 Days) $0 Copay $250 Copay/Day (Up to the first 5 Days) $0 Copay $150 Copay $0 Copay $15 Copay $150 Copay $5 Copay $10 Copay $15 Copay $30 Copay $25 Copay $50 Copay 10% Coinsurance, up to $250 Copay Not Covered 10% Coinsurance 10% Coinsurance 10% Coinsurance $15 Copay $15 Copay $250 Copay/Day (Up to the first 5 Days) $0 Copay $15 Copay $15 Copay $250 Copay/Day (Up to the first 5 Days) $0 Copay $20 Copay $20 Copay $15 Copay $15 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 1/1/2023 12/31/2023 2x
326 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Gold 80 HMO 2023 Individual and Family 2023-gold-80-hmo-ifp HMO 0.801 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 $8,550 / Family $17,100 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 $150 Copay $40 Copay 20% Coinsurance $150 Copay $350 Copay/Day (Up to the first 5 Days) $0 Copay $350 Copay/Day (Up to the first 5 Days) $0 Copay $350 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 1/1/2023 12/31/2023 2x
327 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Silver 70 HMO 2023 Individual and Family 2023-silver-70-hmo-ifp HMO 0.716 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 $4,750 / Family $9,500 Individual $85 / Family $170 Individual $8,750 / Family $17,500 None $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $45 Copay $85 Copay $45 Copay $45 Copay $45 Copay $85 Copay $45 Copay $50 Copay $95 Copay $325 Copay 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance After Deductible, 30% Coinsurance 30% Coinsurance After Deductible, 30% Coinsurance 30% Coinsurance $400 Copay $0 Copay $45 Copay $250 Copay After Drug Deductible, $16 Copay After Drug Deductible, $32 Copay After Drug Deductible, $60 Copay After Drug Deductible, $120 Copay After Drug Deductible, $90 Copay After Drug Deductible, $180 Copay After Drug Deductible, 20% Coinsurance, up to $250 Copay Not Covered 20% Coinsurance 20% Coinsurance 20% Coinsurance $45 Copay $45 Copay After Deductible, 30% Coinsurance 30% Coinsurance $45 Copay $45 Copay After Deductible, 30% Coinsurance 30% Coinsurance $45 Copay $45 Copay $45 Copay $45 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 1/1/2023 12/31/2023 2x SFC02
328 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Bronze 60 HMO 2023 Individual and Family 2023-bronze-60-hmo-ifp HMO 0.645 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 $6,300 / Family $12,600 Individual $500 / Family $1,000 Individual $8,200 / Family $16,400 None $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $65 Copay for the first 3 non-preventive visits, then Deductible Applies $95 Copay for the first 3 non-preventive visits, then Deductible Applies $65 Copay for the first 3 non-preventive visits, then Deductible Applies $65 Copay for the first 3 non-preventive visits, then Deductible Applies $65 Copay for the first 3 non-preventive visits, then Deductible Applies $95 Copay for the first 3 non-preventive visits, then Deductible Applies $65 Copay for the first 3 non-preventive visits, then Deductible Applies $40 Copay After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance $0 Copay $65 Copay for the first 3 non-preventive visits, then Deductible Applies After Deductible, 40% Coinsurance After Drug Deductible, $18 Copay After Drug Deductible, $36 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 $65 Copay for the first 3 non-preventive visits, then Deductible Applies After Deductible, 40% Coinsurance, up to $65 Copay After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance $65 Copay for the first 3 non-preventive visits, then Deductible Applies After Deductible, 40% Coinsurance, up to $65 Copay After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance After Deductible, 40% Coinsurance $65 Copay $65 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 1/1/2023 12/31/2023 2x
329 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Bronze 60 HDHP HMO 2023 Individual and Family 2023-bronze-60-hdhp-hmo-ifp HDHP 0.642 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 $7,000 / Family $14,000 (Combined Medical/Drug Deductible) Individual $7,000 / Family $14,000 (Combined Medical/Drug Deductible) Individual $7,000 / Family $14,000 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 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 Drug Deductible, 0% Coinsurance After Drug Deductible, 0% Coinsurance After Drug Deductible, 0% Coinsurance After Drug Deductible, 0% Coinsurance After Drug Deductible, 0% Coinsurance After Drug Deductible, 0% Coinsurance After 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 1/1/2023 12/31/2023 2x
330 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM American Indian / Alaskan Native $0 Cost Sharing 2023 Individual and Family 2023-american-indian-alaskan-native-hmo-ifp HMO 1 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 1/1/2023 12/31/2023 2x SFC02
331 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Minimum Coverage HMO 2023 Individual and Family 2023-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 $9,100 / Family $18,200 (Combined Medical/Drug Deductible) Individual $9,100 / Family $18,200 (Combined Medical/Drug Deductible) Individual $9,100 / Family $18,200 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 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 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 1/1/2023 12/31/2023 2x
332 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Silver 94 HMO 2023 Individual and Family 2023-silver-94-hmo-ifp HMO 0.949 Subsidized plan that pays 94% of medical expenses. Individuals & Families that qualify for a subsidy based on income. Yes Individual $75 / Family $150 None Individual $900 / Family $1,800 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 10% Coinsurance After Deductible, 10% Coinsurance 10% Coinsurance After Deductible, 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 After Deductible, 10% Coinsurance 10% Coinsurance $5 Copay $5 Copay After Deductible, 10% Coinsurance 10% Coinsurance $3 Copay $3 Copay $5 Copay $5 Copay After Deductible, 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 1/1/2023 12/31/2023 2x SFC02
333 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Silver 87 HMO 2023 Individual and Family 2023-silver-87-hmo-ifp HMO 0.879 Subsidized plan that pays 87% of medical expenses. Individuals & Families that qualify for a subsidy based on income. Yes Individual $800 / Family $1,600 Individual $25 / Family $50 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 15% Coinsurance 15% Coinsurance 15% Coinsurance 15% Coinsurance After Deductible, 25% Coinsurance 25% Coinsurance After Deductible, 25% Coinsurance 25% 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 After Deductible, 25% Coinsurance 25% Coinsurance $15 Copay $15 Copay After Deductible, 25% Coinsurance 25% Coinsurance $15 Copay $15 Copay $15 Copay $15 Copay After Deductible, 25% 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 1/1/2023 12/31/2023 2x SFC02
334 imLana 02/10/2026 09:08 AM imLana 02/10/2026 09:08 AM Silver 73 HMO 2023 Individual and Family 2023-silver-73-hmo-ifp HMO 0.739 Subsidized plan that pays 73% of medical expenses. Individuals & Families that qualify for a subsidy based on income. Yes Individual $4,750 / Family $9,500 Individual $30 / Family $60 Individual $7,250 / Family $14,500 None $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $45 Copay $85 Copay $45 Copay $45 Copay $45 Copay $85 Copay $45 Copay $50 Copay $90 Copay $325 Copay 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance After Deductible, 30% Coinsurance 30% Coinsurance After Deductible, 30% Coinsurance 30% Coinsurance $400 Copay $0 Copay $45 Copay $250 Copay After Drug Deductible, $16 Copay After Drug Deductible, $32 Copay After Drug Deductible, $55 Copay After Drug Deductible, $110 Copay After Drug Deductible, $85 Copay After Drug Deductible, $170 Copay After Drug Deductible, 20% Coinsurance, up to $250 Copay Not Covered 20% Coinsurance 20% Coinsurance 20% Coinsurance $45 Copay $45 Copay After Deductible, 30% Coinsurance 30% Coinsurance $45 Copay $45 Copay After Deductible, 30% Coinsurance 30% Coinsurance $40 Copay $40 Copay $45 Copay $45 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 1/1/2023 12/31/2023 2x 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