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Benefits and Cost Sharing PUF

Business Year

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State Code

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Issuer Id

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Source Name

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Version Number

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Import Date

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Issuer Id (Repeated)

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State Code (Repeated)

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Plan Id

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Plan Id (Standard Component Id With Variant)

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Benefit Name

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Copay In Network (Tier 1)

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Copay In Network (Tier 2)

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Copay Out Of Network

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Coinsurance In Network (Tier 1)

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Coinsurance In Network (Tier 2)

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Coinsurance Out Of Network

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Ehb Indicator

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State Required Benefit Indicator

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Is This Benefit Covered?

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Quantitative Limit On Service

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Limit Quantity

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Limit Unit

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Minimum Stay

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Exclusions

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Explanation

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Ehb Variance Reason

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Is Subject To Deductible Tier 1

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Is Subject To Deductible Tier 2

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Is Excluded From In Network Moop

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Is Excluded From Out Of Network Moop

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Row Number

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2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-05
Durable Medical Equipment
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
95
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-06
Infertility Treatment
Not Covered
69
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600008
38344AK0600008-02
Hospice Services
No Charge
No Charge
0%
0%
t
Covered
t
10
Days per Lifetime
Respite care 240 hours within the 6 month lifetime maximum
Substantially Equal
t
f
f
f
66
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600004
38344AK0600004-04
Hearing Aids
Not Covered
96
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600007
38344AK0600007-02
Substance Abuse Disorder Outpatient Services
No Charge
No Charge
0%
0%
t
Covered
f
t
f
f
f
86
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980005
38344AK0980005-01
Acupuncture
$15
No Charge
No Charge
60% Coinsurance after deductible
t
Covered
t
12
Visit(s) per Year
12 Visits PCY
Substantially Equal
f
f
f
f
100
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980006
38344AK0980006-01
Specialist Visit
$45
No Charge
No Charge
60% Coinsurance after deductible
t
Covered
f
f
f
f
f
62
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0570002
38344AK0570002-04
Rehabilitative Occupational and Rehabilitative Physical Therapy
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
Covered
t
45
Visit(s) per Year
45 Visits PCY combined for outpatient services
Additional EHB Benefit
t
f
f
f
106
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620006
38344AK0620006-04
Infertility Treatment
Not Covered
69
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620003
38344AK0620003-01
Skilled Nursing Facility
$0 Copay per Day
$0 Copay per Day
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
t
60
Days per Year
t
f
f
f
81
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0570002
38344AK0570002-06
Preferred Brand Drugs
No Charge
No Charge
20% Coinsurance after deductible
20% Coinsurance after deductible
t
Covered
t
90
Item(s) per Month
90 day Retail and Mail order
Substantially Equal
t
f
f
f
89
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0930004
38344AK0930004-01
Specialist Visit
$30
$30
No Charge
No Charge
t
Covered
f
f
f
f
t
62
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630001
38344AK0630001-01
Clinical Trials
No Charge
No Charge
0% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
Additional EHB Benefit
t
t
f
f
129
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980005
38344AK0980005-01
Home Health Care Services
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
t
130
Visit(s) per Year
130 Visits PCY
Substantially Equal
t
f
f
f
74
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620006
38344AK0620006-01
Chemotherapy
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
Covered
f
Additional EHB Benefit
t
f
f
f
121
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620007
38344AK0620007-01
Prenatal and Postnatal Care
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
82
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600004
38344AK0600004-06
Emergency Transportation/Ambulance
No Charge
No Charge
20% Coinsurance after deductible
20% Coinsurance after deductible
t
Covered
f
t
f
f
t
76
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-01
Preferred Brand Drugs
No Charge
No Charge
20% Coinsurance after deductible
20% Coinsurance after deductible
t
Covered
t
90
Item(s) per Month
90 day Retail and Mail order
Substantially Equal
t
f
f
f
89
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980006
38344AK0980006-01
Durable Medical Equipment
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
95
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620007
38344AK0620007-02
Orthodontia - Adult
Not Covered
114
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630001
38344AK0630001-02
Other Practitioner Office Visit (Nurse, Physician Assistant)
No Charge
No Charge
0%
0%
t
Covered
f
t
f
f
f
63
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980003
38344AK0980003-01
Other Practitioner Office Visit (Nurse, Physician Assistant)
$10
No Charge
No Charge
60% Coinsurance after deductible
t
Covered
f
f
f
f
f
63
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620006
38344AK0620006-05
Mental/Behavioral Health Inpatient Services
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
85
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-05
Other Practitioner Office Visit (Nurse, Physician Assistant)
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
63
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-02
Prosthetic Devices
No Charge
No Charge
0%
0%
Covered
f
Additional EHB Benefit
t
f
f
f
124
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600003
38344AK0600003-01
Preventive Care/Screening/Immunization
$0
$0
No Charge
No Charge
t
t
Covered
f
f
f
f
t
98
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-03
Hearing Aids
Not Covered
96
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0570001
38344AK0570001-01
Specialty Drugs
No Charge
No Charge
0% Coinsurance after deductible
100%
t
Covered
t
30
Item(s) per Month
30 day Retail and Mail order
Substantially Equal
t
f
f
f
91
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600002
38344AK0600002-03
Cosmetic Surgery
Not Covered
80
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0930005
38344AK0930005-01
Non-Emergency Care When Traveling Outside the U.S.
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
Additional EHB Benefit
t
f
f
f
67
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620007
38344AK0620007-03
Laboratory Outpatient and Professional Services
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
108
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620002
38344AK0620002-03
Basic Dental Care - Child
No Charge
No Charge
20% Coinsurance after deductible
40% Coinsurance after deductible
t
Covered
t
4
Procedure(s) per Year
Substantially Equal
t
f
f
f
110
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600007
38344AK0600007-02
Prenatal and Postnatal Care
No Charge
No Charge
0%
0%
t
Covered
f
t
f
f
f
82
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600006
38344AK0600006-06
Other Practitioner Office Visit (Nurse, Physician Assistant)
$20
$20
No Charge
No Charge
t
Covered
f
f
f
f
t
63
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600006
38344AK0600006-05
Orthodontia - Adult
Not Covered
114
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620008
38344AK0620008-03
Outpatient Surgery Physician/Surgical Services
No Charge
No Charge
0% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
65
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600007
38344AK0600007-03
Hospice Services
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
t
10
Days per Lifetime
Respite care 240 hours within the 6 month lifetime maximum
Substantially Equal
t
f
f
f
66
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-05
Basic Dental Care - Child
No Charge
No Charge
20% Coinsurance after deductible
40% Coinsurance after deductible
t
Covered
t
4
Procedure(s) per Year
Substantially Equal
t
f
f
f
110
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0930004
38344AK0930004-01
Mental/Behavioral Health Outpatient Services
No Charge
No Charge
20%
60% Coinsurance after deductible
t
Covered
f
f
f
f
f
84
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620004
38344AK0620004-01
Laboratory Outpatient and Professional Services
No Charge
No Charge
20%
60% Coinsurance after deductible
t
Covered
f
f
f
f
f
108
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600006
38344AK0600006-04
Inherited Metabolic Disorder - PKU
No Charge
No Charge
20% Coinsurance after deductible
20% Coinsurance after deductible
t
Covered
f
Additional EHB Benefit
t
t
f
f
131
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0950001
38344AK0950001-01
Inherited Metabolic Disorder - PKU
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
t
Covered
f
t
f
f
f
131
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630001
38344AK0630001-02
Primary Care Visit to Treat an Injury or Illness
No Charge
No Charge
0%
0%
t
Covered
f
t
f
f
f
61
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0570001
38344AK0570001-02
Basic Dental Care - Child
No Charge
No Charge
0%
0%
t
Covered
t
4
Procedure(s) per Year
Substantially Equal
t
f
f
f
110
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0630002
38344AK0630002-05
Orthodontia - Child
No Charge
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Covered
f
Unlimited if Medically Necessary only
Additional EHB Benefit
t
f
f
f
111
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0930005
38344AK0930005-01
Specialist Visit
$35
$35
No Charge
No Charge
t
Covered
f
f
f
f
t
62
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0600008
38344AK0600008-01
Nutritional Counseling
$0
$0
No Charge
No Charge
Covered
f
Additional EHB Benefit
f
f
f
t
127
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0980011
38344AK0980011-01
Diabetes Education
$0
$0
No Charge
No Charge
Covered
f
Additional EHB Benefit
f
f
f
f
123
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0620008
38344AK0620008-01
Specialist Visit
$50
No Charge
No Charge
60% Coinsurance after deductible
t
Covered
f
f
f
f
f
62
2015
AK
38344
OPM
10
2014-12-12 12:37:00
38344
AK
38344AK0610002
38344AK0610002-04
Chemotherapy
No Charge
No Charge
20% Coinsurance after deductible
60% Coinsurance after deductible
Covered
f
Additional EHB Benefit
t
f
f
f
121

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