Benefits and Cost Sharing PUF | Namara Marketplace

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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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